Vomiting After Outpatient Tonsillectomy and Adenoidectomy in Children

Patient outcomes following ambulatory anesthesia

As the number and type of surgeries performed in the ambulatory setting have increased, outcomes research has allowed for better analysis of the safety and efficacy of care given to patients. Though this once involved measures of clinical morbidity and mortality alone, researchers have begun to focus their attention beyond these end points and take into account patients' postoperative functional status and satisfaction as a way to assess the overall quality of patient care. Also key in this move to a more global assessment of health care interventions has been an increased focus on economic outcomes. As new anesthetic drugs and techniques continue to develop, outcomes research will continue to evolve in new directions, providing further information for improvements in patient care.

Effects of anesthetic technique on side effects associated with fentanyl Oralet premedication

STUDY OBJECTIVES

To evaluate the efficacy of 5 to 10 micrograms/kg of oral transmucosal fentanyl citrate (OTFC) as an anesthetic premedication, and to determine whether propofol induction reduces postoperative nausea and vomiting (PONV) in pediatric patients premedicated with OTFC undergoing outpatient surgery.

DESIGN

Prospective, randomized, double-blinded study.

SETTINGS

University of Michigan Health Care Systems and University of Arizona.

PARTICIPANTS

62 ASA physical status I and II children aged 4 to 14 years (8.9 +/- 0.5 years).

INTERVENTIONS

Subjects were randomly assigned to one of four groups: (1) OTFC premedication and halothane induction; (2) OTFC premedication and propofol induction; (3) placebo premedication and halothane induction; and (4) placebo premedication and propofol induction. OTFC or placebo was administered 30 minutes prior to induction, and activity (sedation), apprehension, and cooperation scores were recorded before, at 15 and 30 minutes after study drug, and on induction. All perioperative adverse events were recorded.

MEASUREMENTS AND MAIN RESULTS

Children who received OTFC became drowsier and had a significant change from baseline in combined activity, apprehension, and cooperation scores, whereas those who received placebo became less cooperative at induction. Patients who received OTFC experienced more adverse events overall (p < 0.001) than patients who received placebo. Additionally, OTFC patients experienced more vomiting (p < 0.001) and pruritus (p = 0.049) than controls. The incidence of PONV in patients who received OTFC and halothane induction was 50%, compared to 30% in patients receiving OTFC and a propofol induction (p = NS).

CONCLUSIONS

OTFC in doses of 5 to 10 micrograms/kg was effective in producing sedation and facilitating cooperation with induction; however, it was associated with significant PONV in our study. Although propofol induction did not significantly reduce PONV in our study, further study with a larger sample, and with propofol as the sole anesthetic, may be warranted.

Inadequate pain management and associated morbidity in children at home after tonsillectomy

A telephone interview with the parents of 84 children who underwent tonsillectomy was conducted within 24 hours after discharge from an ambulatory surgery center. Parents were asked to rate the intensity of their child's pain and data were collected on the type, dose, and amount of analgesics administered, and the types of side effects the children experienced. The mean age of the children was 7 years (SD = 2.31), with an equal number of boys and girls. Overall mean pain intensity was 1.42 (SD = 0.71) and the worst pain intensity ranged from 0 to 3 (Mean = 1.93; SD = 0.83). Acetaminophen with codeine was the most common analgesic prescribed and administered. Children received an average of 3 doses in the first 24 hours after surgery. Seventy-seven percent of the parents stated that pain relief from the analgesic was adequate. Of the 23% who did not feel that pain control was adequate, only 7% contacted a physician. The majority of the children experienced restless sleep (62%), behavior changes (75%), and difficulty taking oral fluids because of complaints of pain (56%). Twenty-six percent of the children had one or more episodes of emesis. Our data suggest that children experience a significant amount of pain in the first 24 hours after tonsillectomy and that parents administer analgesics less frequently than the drugs are prescribed. In addition, children experience significant deleterious effects (i.e., poor oral fluid intake, sleep disturbance, behavioral changes, and emesis) associated with the undertreatment of pain, the analgesic administered, or the surgery itself.

Postoperative nausea and vomiting: the outpatient enigma

Postoperative nausea and vomiting is an all too common side effect of surgery and anesthesia. The usual occurrence of vomiting within the first 24 hours following surgery involves one quarter to one third of all patients. Although nausea and vomiting is typically self-limiting, lasting less than 24 hours, the consequences must be considered. Patient dissatisfaction, adverse physiological sequelae, delays in discharge from the ambulatory facility, unanticipated hospital admission, and added cost are problems associated with postoperative vomiting. This article will review the multiple factors contributing to postoperative nausea and vomiting and discuss contemporary strategies for the management of these factors.