Reducing postoperative nausea and vomiting in pediatric patients undergoing anterior cruciate ligament reconstruction: A quality report.

BACKGROUND: Postoperative nausea and vomiting after elective outpatient surgery can complicate discharge and increase patient suffering. Within our hospital system, there was variability in the use of postoperative nausea and vomiting prophylaxis for patients undergoing anterior cruciate ligament reconstruction, which resulted in variable outcomes. To address this variability, we designed and implemented a standardized postoperative nausea and vomiting prophylaxis guideline for the care of this surgical population. AIM: We sought to develop and implement a standardized postoperative nausea and vomiting prophylaxis guideline for all patients presenting for elective ambulatory anterior cruciate ligament reconstruction with the goal of reducing the rate of emesis to ≤5%. METHODS: We convened a multidisciplinary team to develop a postoperative nausea and vomiting prophylaxis guideline which included administration of dexamethasone, ondansetron, and a low-dose propofol infusion in addition to a femoral and sciatic nerve block and routine ketorolac administration for pain control. Our primary outcome, emesis rate, was tracked using a P-chart. Process measures included use of guideline medications and balancing measures included opioid administration, pain scores, and emergence time. RESULTS: We analyzed postoperative nausea and vomiting outcomes for 817 patients from January 1, 2014, to December 31, 2018. The baseline postoperative emesis rate for all anesthetizing locations was 17%. Following, guideline implementation, the emesis rate decreased to 5%. Opioid administration was decreased following guideline implementation. The percentage of patients managed without any perioperative opioids increased from 16% in the baseline group to 38% following guideline implementation. The P-chart suggests that the observed reduction in emesis rate represents special cause variation and this reduction was sustained over a two-year period. CONCLUSIONS: Implementation of standard postoperative nausea and vomiting guidelines for adolescents undergoing outpatient anterior cruciate ligament reconstruction was associated with lower emesis rates. This reduction in emesis rate may have been due to the concurrent reduction in opioids we observed following guideline implementation.

Comparative Safety of Morphine Delivered via Intravenous Route vs. Patient-Controlled Analgesia Device for Pediatric Inpatients.

CONTEXT: Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients. OBJECTIVES: This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database. METHODS: We assembled a retrospective cohort of pediatric inpatients between five and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System database. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and nonsurgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to two days after drug administration. RESULTS: Surgical and nonsurgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to two days after PCA exposure, although these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20%-44% lower odds of same day CPR in both surgical and nonsurgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients. CONCLUSION: In this large pediatric inpatient population, morphine administered via PCA device for surgical and nonsurgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.