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Messerer B, Stijic M, Sandner-Kiesling A, Brillinger JM, Helm J, Scheer J, Strohmeier CS, Avian A. Is PONV still a problem in pediatric surgery: a prospective study of what children tell us. Front Pediatr 2023; 11:1241304. [PMID: 37964809 PMCID: PMC10642485 DOI: 10.3389/fped.2023.1241304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
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.
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Affiliation(s)
- Brigitte Messerer
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Marko Stijic
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
- University Clinic for Neurology, Clinical Department for Neurogeriatrics, Medical University of Graz, Graz, Austria
| | - Andreas Sandner-Kiesling
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Johanna M. Brillinger
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Jasmin Helm
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Jacqueline Scheer
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Christof Stefan Strohmeier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
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Pillai Riddell RR, Bucsea O, Shiff I, Chow C, Gennis HG, Badovinac S, DiLorenzo-Klas M, Racine NM, Ahola Kohut S, Lisi D, Turcotte K, Stevens B, Uman LS. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev 2023; 6:CD006275. [PMID: 37314064 PMCID: PMC10265939 DOI: 10.1002/14651858.cd006275.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title. OBJECTIVES To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update. We also searched reference lists and contacted researchers via electronic list-serves. We incorporated 76 new studies into the review. SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis. DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes. MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence. In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements. AUTHORS' CONCLUSIONS Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.
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Affiliation(s)
| | - Oana Bucsea
- Department of Psychology, York University, Toronto, Canada
| | - Ilana Shiff
- Department of Psychology, York University, Toronto, Canada
| | - Cheryl Chow
- Department of Psychology, York University, Toronto, Canada
| | | | | | | | - Nicole M Racine
- Department of Psychology, University of Calgary, Calgary, Canada
| | - Sara Ahola Kohut
- Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Diana Lisi
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Kara Turcotte
- Department of Psychology, University of British Columbia Okanagan, Kelowna, Canada
| | - Bonnie Stevens
- Nursing Research, The Hospital for Sick Children, Toronto, Canada
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Goal-directed fluid therapy guided by Plethysmographic Variability Index (PVI) versus conventional liberal fluid administration in children during elective abdominal surgery: A randomized controlled trial. J Pediatr Surg 2023; 58:735-740. [PMID: 36631313 DOI: 10.1016/j.jpedsurg.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 11/17/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND PVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery. METHODS 42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either 'conventional liberal intraoperative fluids' (liberal group) or 'goal-directed intraoperative fluids' (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes. RESULTS The mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001). CONCLUSION Intraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy. TYPE OF STUDY Randomized Clinical Trial. LEVEL OF EVIDENCE Treatment Study (LEVEL 1).
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4
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Schlesinger T, Weibel S, Kranke P. Postoperative/postdischarge nausea and vomiting: evidence-based prevention and treatment. Curr Opin Anaesthesiol 2023; 36:109-116. [PMID: 36214542 DOI: 10.1097/aco.0000000000001200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Postoperative/postdischarge nausea and vomiting (PONV/PDNV) remains a relevant issue in perioperative care. Especially in outpatient surgery, PONV can prevent discharge or lead to unplanned readmission. RECENT FINDINGS Evidence on prophylaxis and treatment of PONV is growing, but implementation remains poor. SUMMARY A liberal, universal PONV management is now endorsed by the guidelines. Specific evidence concerning prevention and (at-home) treatment of PDNV is still scarce.
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Affiliation(s)
- Tobias Schlesinger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Wuerzburg, Wuerzburg, Germany
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5
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Puri S, Bandyopadhyay A, Ashok V. Supplemental intraoperative crystalloids for pediatric postoperative nausea and vomiting-A systematic review and meta-analysis. Paediatr Anaesth 2023; 33:38-45. [PMID: 36178763 DOI: 10.1111/pan.14566] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/24/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative nausea and/or vomiting is a relatively frequent occurrence after general anesthesia in pediatric patients. Supplemental perioperative crystalloid fluid administration has been shown to have a positive effect on the incidence of nausea and/or vomiting in adults undergoing surgery. The question arises whether supplemental intraoperative intravenous fluids in pediatric patients offers beneficial results with regards to pediatric postoperative nausea and/or vomiting. METHODS Pubmed, EMBASE, Google Scholar, and Web of Science were searched up to March 2022 to perform a systematic review with meta-analysis of randomized controlled trials involving patients ≤18 years undergoing elective surgery under general anesthesia, with one group receiving conventional intraoperative fluids therapy and the other group receiving supplemental intraoperative fluid therapy, with intravenous crystalloids. The outcomes included incidence of postoperative vomiting, postoperative nausea and vomiting, the need for rescue anti-emetics, postoperative thirst, and adverse events attributed to supplemental intravenous fluid therapy. Relative risk (RR) with 95% confidence intervals (CIs) were reported for the outcomes using a random or fixed effects model. RESULTS Seven randomized controlled trials (864 patients) were included in the final analysis. Supplemental intraoperative crystalloids reduce postoperative vomiting (RR 0.56, 95% CI 0.39-0.80; p = .001), postoperative nausea and vomiting (RR 0.52, 95% CI 0.37-0.74; p = .0003), postoperative thirst (RR 0.21, 95% CI 0.13,0.34; p < .01), and the need for rescue anti-emetics postoperatively (RR 0.60, 95% CI 0.49-0.74; p = .00001). CONCLUSION Supplemental intraoperative intravenous crystalloids significantly reduce several PONV outcomes in healthy children undergoing relatively simple and superficial surgeries under volatile agent-based general anesthesia.
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Affiliation(s)
- Sunaakshi Puri
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anjishnujit Bandyopadhyay
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vighnesh Ashok
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Nascimento LAD, Garcia AKA, Conchon MF, Lopes MVDO, Fonseca LF. Concept analysis of Perioperative Thirst for the development of a new nursing diagnosis. Rev Bras Enferm 2021; 74:e20200065. [PMID: 33681954 DOI: 10.1590/0034-7167-2020-0065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/13/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to analyze the perioperative thirst concept for the development of a new diagnostic structure according to NANDA International. METHODS a concept analysis study based on the framework proposed by Walker and Avant, instrumentalized through an integrative literature review based on SCOPUS, CINAHL, PUBMED, LILACS, and WOS. The elaboration of the diagnostic structure followed NANDA International guidelines. RESULTS 41 studies were analyzed revealing that perioperative thirst is prevalent and intense, having visceral and behavioral attributes as the core of the concept. Antecedents indicate that surgical patients are vulnerable to thirst; and consequents 16 signs and symptoms were organized and model cases were developed. A diagnostic structure has been developed for perioperative thirst. FINAL CONSIDERATIONS concept analysis allowed language standardization that describes thirsty patients, helping the identification, planning of actions and communication of perioperative nursing care.
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Abstract
Postoperative nausea and vomiting (PONV), postoperative vomiting (POV), post-discharge nausea and vomiting (PDNV), and opioid-induced nausea and vomiting (OINV) continue to be causes of pediatric morbidity, delay in discharge, and unplanned hospital admission. Research on the pathophysiology, risk assessment, and therapy for PDNV, OINV and pain therapy options in children has received increased attention. Multimodal pain management with the use of perioperative regional and opioid-sparing analgesia has helped decrease nausea and vomiting. Two common emetogenic surgical procedures in children are adenotonsillectomy and strabismus repair. Although PONV risk factors differ between adults and children, the approach to decrease baseline risk is similar. As PONV and POV are frequent in children, antiemetic prophylaxis should be considered for those at risk. A multimodal approach for antiemetic and pain therapy involves preoperative risk evaluation and stratification, antiemetic prophylaxis, and pain management with opioid-sparing medications and regional anesthesia. Useful antiemetics include dexamethasone and serotonin 5-hydroxytryptamine-3 (5-HT3) receptor antagonists such as ondansetron. Multimodal combination prophylactic therapy using two or three antiemetics from different drug classes and propofol total intravenous anesthesia should be considered for children at high PONV risk. "Enhanced recovery after surgery" protocols include a multimodal approach with preoperative preparation, adequate intravenous fluid hydration, opioid-sparing analgesia, and prophylactic antiemetics. PONV guidelines and management algorithms help provide effective postoperative care for pediatric patients.
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Affiliation(s)
- Anthony L Kovac
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 1034, Kansas City, KS, 66160, USA.
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Beiseigel M, Simon BT, Michalak C, Stickney MJ, Jeffery U. Effect of peri-operative crystalloid fluid rate on circulating hyaluronan in healthy dogs: A pilot study. Vet J 2020; 267:105578. [PMID: 33375957 DOI: 10.1016/j.tvjl.2020.105578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 11/13/2020] [Accepted: 11/19/2020] [Indexed: 12/14/2022]
Abstract
Hypervolemia can damage the endothelial glycocalyx, a key regulator of vascular permeability, coagulation and inflammation. A starting peri-operative crystalloid fluid rate of 5mL/kg/h is recommended for healthy dogs undergoing elective procedures but higher rates continue to be commonly used. This study aimed to determine if a higher starting perioperative fluid rate was associated with a greater increase in plasma concentrations of hyaluronan, a marker correlated with glycocalyx damage, in systemically healthy dogs undergoing elective surgical procedures. Based on a sample size calculation, 38 dogs undergoing ovariohysterectomy or castration were randomly assigned to receive lactated Ringer's at a starting perioperative fluid rate of 10mL/kg/h (n=19) or 5mL/kg/h (n=19). Plasma hyaluronan concentrations were measured by ELISA in pre- and post-fluid therapy samples. There were no significant differences between groups in hyaluronan values before (baseline, P=0.52) or after perioperative fluid administration (P=0.62). Compared to respective baseline values, hyaluronan values significantly increased following 5 and 10ml/kg/h fluid administration (P=0.02 for both comparisons). This preliminary study identified an increase in hyaluronan over the course of fluid therapy with both the low and high fluid rate. One possible explanation is that both fluid rates contribute to glycocalyx disruption, but it should be emphasized that hyaluronan is not specific to the glycocalyx. Further studies are needed to determine the origin of the increased circulating hyaluronan and its clinical significance in dogs undergoing elective surgical procedures.
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Affiliation(s)
- M Beiseigel
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - B T Simon
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - C Michalak
- Veterinary Medical Teaching Hospital, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - M J Stickney
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - U Jeffery
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA.
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Jaimes Daza MF, Alarcón Tarazona IE, Duarte Villamizar JA, Meléndez HJ, Torres HH. Incidence of postoperative vomiting in pediatric population undergoing anesthesia: a prospective cohort study. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.5554/22562087.e932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Postoperative nausea and vomiting are frequent adverse effects of anesthesia and surgery. Impact is greater in pediatric populations compared to adults and the reported incidences are heterogeneous.
Objective: To describe the incidence of postoperative vomiting in a pediatric population and to identify associated risk factors.
Materials and methods: This prospective cohort study included 190 children aged 3 to 12 years undergoing surgery and anesthesia in a maternal and child health clinic in Bucaramanga (Colombia). The main outcome variable was postoperative vomiting. Data were analyzed using bivariate, multivariate analysis and logistic regression to assess the associated risk factors.
Results: The overall incidence of postoperative vomiting was 18.95% (95% CI: 13.32 - 24.57), with a higher incidence at home vs. hospital (12.63% vs. 9.47%). After adjustment, associated risk factors were anesthesia time longer than 45 minutes (OR: 2.33; 95% CI: 1.10-4.90) and postoperative use of opioids (OR: 4.17; 95% IC: 1.65-10.5). The incidence of postoperative vomiting was higher in patients who underwent emergency surgery.
Conclusion: This is the first study in Colombia that evaluates the incidence of postoperative vomiting in children. The incidence in our pediatric population is within the ranges reported worldwide. Associated risk factors were anesthesia time longer than 45 minutes and postoperative use of opioids. Further research is required in order to study emergency surgery as a potential risk factor.
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Elvir-Lazo OL, White PF, Yumul R, Cruz Eng H. Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review. F1000Res 2020; 9. [PMID: 32913634 PMCID: PMC7429924 DOI: 10.12688/f1000research.21832.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/10/2023] Open
Abstract
Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.
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Affiliation(s)
| | - Paul F White
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.,The White Mountain Institute, The Sea Ranch, Sonoma, CA, 95497, USA.,Instituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.,David Geffen School of Medicine-UCLA, Charles R. Drew University of Medicine and Science, Los Angeles, CA, 90095, USA
| | - Hillenn Cruz Eng
- Department of Anesthesiology, PennState Hershey Medical Center, Hershey, PA, 17033, USA
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Ames WA, Machovec K. An update on the management of PONV in a pediatric patient. Best Pract Res Clin Anaesthesiol 2020; 34:749-758. [PMID: 33288124 DOI: 10.1016/j.bpa.2020.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 11/27/2022]
Abstract
Postoperative nausea and vomiting (PONV) is a major cause of patient dissatisfaction following anesthesia. The difficulty in diagnosing nausea in much of the pediatric population has led to an emphasis on anti-emetic prophylaxis for all. Assessment scores and prognostic tools enable the anesthesiologist to identify patients who are at a greater risk and appropriately apply more aggressive prophylactic, multi-drug strategies. New antiemetics emerging from other medical disciplines, particularly oncology, may have potential use in prophylaxis and treatment of nausea and vomiting in the pediatric surgical population. New agents, many of which have a long duration of action, will augment the anesthesiologist's ability to adequately prevent PONV, and to treat persistent nausea and vomiting that extend beyond the immediate post-operative period.
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Affiliation(s)
- Warwick Aubrey Ames
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA.
| | - Kelly Machovec
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27710, USA.
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An Enhanced Recovery Protocol that Facilitates Same-day Discharge for Simple Laparoscopic Appendectomies. Pediatr Qual Saf 2019; 4:e243. [PMID: 32010869 PMCID: PMC6946221 DOI: 10.1097/pq9.0000000000000243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022] Open
Abstract
Acute appendicitis is the most common gastrointestinal condition requiring urgent operation in the pediatric population with laparoscopic appendectomy (LA) being the current surgical technique. We describe the implementation of a standardized protocol to reduce postoperative nausea and vomiting (PONV) and facilitate same-day discharge after LA.
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Urits I, Orhurhu V, Jones MR, Adamian L, Borchart M, Galasso A, Viswanath O. Postoperative Nausea and Vomiting in Paediatric Anaesthesia. Turk J Anaesthesiol Reanim 2019; 48:88-95. [PMID: 32259138 PMCID: PMC7101192 DOI: 10.5152/tjar.2019.67503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/01/2019] [Indexed: 02/01/2023] Open
Abstract
Postoperative nausea and vomiting (PONV) is a common complication in paediatric anaesthesia and is a source of significant morbidity. Various independent risk factors have been implicated in the development of paediatric PONV, including higher pain scores postoperatively, the use of opioids for pain management and the use of volatile anaesthetics for the maintenance of anaesthesia. This review of the current literature regarding the prevention and treatment of paediatric PONV is based on a search of the PubMed database, which identified published clinical trials, systematic reviews and meta-analyses. While the occurrence of PONV in many cases is difficult to avoid entirely, the risk can be mitigated by the use of multimodal nonopioid analgesic regimens, total intravenous drugs in favour of volatile anaesthetics and an appropriate regimen of prophylactic pharmacotherapy. Frequently administered drug classes for the prevention of PONV include corticosteroids, 5HT3 antagonists and anticholinergics. The clinical use of the findings in the literature may help to reduce the occurrence of PONV in children. In this review, we provide comprehensive and updated information on the risk factors contributing the occurrence of PONV in children, outline the current opinion on the drugs that are commonly used for management and provide an overview of the guidelines that are used to help establish the prophylaxis and treatment of paediatric PONV.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Mark R Jones
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Leena Adamian
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Matthew Borchart
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | | | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ; University of Arizona College of Medicine Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA
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Silverman RA, House SL, Meltzer AC, Hahn B, Lovato LM, Avarello J, Miller JB, Kalfus IN, Fathi R, Raday G, Plasse TF, Yan EC. Bimodal Release Ondansetron for Acute Gastroenteritis Among Adolescents and Adults: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1914988. [PMID: 31702802 PMCID: PMC6902785 DOI: 10.1001/jamanetworkopen.2019.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting. OBJECTIVE To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration. DESIGN, SETTING, AND PARTICIPANTS This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours' duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017. INTERVENTION Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron. MAIN OUTCOMES AND MEASURES Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration. RESULTS Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02246439.
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Affiliation(s)
- Robert A Silverman
- Feinstein Institute for Medical Research, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
- Department of Emergency Medicine, Northwell Health, New York, New York
| | - Stacey L House
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Andrew C Meltzer
- School of Medicine and Health Sciences, Department of Emergency Medicine, George Washington University, Washington, DC
| | - Barry Hahn
- Department of Emergency Medicine, Northwell Health, New York, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Luis M Lovato
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California
| | - Jahn Avarello
- Department of Emergency Medicine, Northwell Health, New York, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
- Cohens Childrens Medical Center, Department of Pediatrics, Northwell Health, New York, New York
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | | | | | | | | | - Eric C Yan
- Atlantic Research Group, Charlottesville, Virginia
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Jewer JK, Wong MJ, Bird SJ, Habib AS, Parker R, George RB. Supplemental peri‐operative intravenous crystalloids for postoperative nausea and vomiting: an abridged Cochrane systematic review. Anaesthesia 2019; 75:254-265. [DOI: 10.1111/anae.14857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2019] [Indexed: 12/11/2022]
Affiliation(s)
- J. K. Jewer
- Department of Anesthesia, Pain Management and Perioperative Medicine Dalhousie University Halifax NS Canada
| | - M. J. Wong
- Department of Anesthesia, Pain Management and Perioperative Medicine Dalhousie University Halifax NS Canada
| | - S. J. Bird
- Department of Anesthesia, Pain Management and Perioperative Medicine Dalhousie University Halifax NS Canada
| | - A. S. Habib
- Duke University Medical Center Durham NC USA
| | - R. Parker
- W.K. Kellogg Health Sciences Library Dalhousie University Halifax NS Canada
| | - R. B. George
- Department of Anaesthesia and Perioperative Care University of California, San Francisco CA USA
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Jewer JK, Wong MJ, Bird SJ, Habib AS, Parker R, George RB. Supplemental perioperative intravenous crystalloids for postoperative nausea and vomiting. Cochrane Database Syst Rev 2019; 3:CD012212. [PMID: 30925195 PMCID: PMC6440702 DOI: 10.1002/14651858.cd012212.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common complication following general anaesthesia. It may be associated with patient dissatisfaction, increased costs of treatment, and unintended admission to hospital.Supplemental intravenous crystalloid administration in the perioperative period may be a simple intervention to prevent PONV. OBJECTIVES To assess whether supplemental intravenous crystalloid administration prevents PONV in patients undergoing surgical procedures under general anaesthesia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE (1946 to August 2018), Embase (1947 to August 2018), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL; 1971 to August 2018). We searched clinical trials registers for ongoing or unpublished completed studies (August 2018), handsearched three major journals (British Journal of Anaesthesia, European Journal of Anaesthesiology, and Anesthesiology; August 2018), and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA We included randomized controlled trials of participants older than six months undergoing surgical procedures under general anaesthesia and given supplemental perioperative intravenous crystalloids, defined as a volume larger than that received by a comparator group, to prevent PONV. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures described by Cochrane. MAIN RESULTS We included 41 studies (4224 participants). Participants underwent ambulatory or short length of stay surgical procedures, and were predominantly American Society of Anesthesiology (ASA) class I or II. There is one study awaiting classification and three ongoing studies. All studies took place in surgical centres, and were conducted in geographically diverse settings. Risk of bias was generally unclear across all domains.Supplemental intravenous crystalloid administration probably reduces the cumulative risk of postoperative nausea (PON) (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.51 to 0.75; 18 studies; 1766 participants; moderate-certainty evidence). When the postoperative period was divided into early (first six hours postoperatively) and late (at the time point closest to or including 24 hours postoperatively) time points, the intervention reduced the risk of early PON (RR 0.67, 95% CI 0.58 to 0.78; 20 studies; 2310 participants; moderate-certainty evidence) and late PON (RR 0.47, 95% CI 0.32 to 0.69; 17 studies; 1682 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the risk of postoperative vomiting (POV) (RR 0.50, 95% CI 0.40 to 0.63; 20 studies; 1970 participants; moderate-certainty evidence). The intervention specifically reduced both early POV (RR 0.56, 95% CI 0.41 to 0.76; 19 studies; 1998 participants; moderate-certainty evidence) and late POV (RR 0.48, 95% CI 0.29 to 0.79; 15 studies; 1403 participants; moderate-certainty evidence).Supplemental intravenous crystalloid administration probably reduces the need for pharmacologic treatment of PONV (RR 0.62, 95% CI 0.51 to 0.76; 23 studies; 2416 participants; moderate-certainty evidence).The effect of supplemental intravenous crystalloid administration on the risk of unplanned postoperative admission to hospital is unclear (RR 1.05, 95% CI 0.77 to 1.43; 3 studies; 235 participants; low-certainty evidence).No studies reported serious adverse events that may occur following supplemental perioperative intravenous crystalloid administration (i.e. admission to high-dependency unit, postoperative cardiac or respiratory complication, or death). AUTHORS' CONCLUSIONS There is moderate-certainty evidence that supplemental perioperative intravenous crystalloid administration reduces PON and POV, in ASA class I to II patients receiving general anaesthesia for ambulatory or short length of stay surgical procedures. The intervention probably also reduces the risk of pharmacologic treatment for PONV. The effect of the intervention on the risk of unintended postoperative admission to hospital is unclear. The risk of serious adverse events resulting from supplemental perioperative intravenous crystalloid administration is unknown as no studies reported this outcome. The one study awaiting classification may alter the conclusions of the review once assessed.
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Affiliation(s)
- James K Jewer
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
| | - Michael J Wong
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
| | - Sally J Bird
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
- IWK Health CentreDepartment of Pediatric Anesthesia5850/5890 University AvenueHalifaxNSCanadaB3P 0B7
| | | | - Robin Parker
- Dalhousie UniversityW.K. Kellogg Health Sciences Library5850 College StPO Box 15000HalifaxNSCanadaB3H 4R2
| | - Ronald B George
- Dalhousie UniversityDepartment of Anesthesia, Pain Management and Perioperative Medicine10 West Victoria1276 South Park StreetHalifaxNSCanadaB3H 2Y9
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