[Pediatric postoperative quality analysis : Pain and postoperative nausea and vomiting]

For the evaluation of postoperative pain therapy, nausea and vomiting (PONV), the Children's Hospital in Lucerne acts as a member of the postoperative quality improvement project QUIPSi for children. Initial results and the potential for evaluation of the postoperative pain therapy and PONV are presented here. The central questions are whether the postoperative therapy concept is sufficient and if QUIPSi serves as an ideal tool for postoperative quality improvement?

Over a period of 1.5 years a total of 460 children aged between 4 to 17 years evaluated their postoperative pain, requirements for more analgesic medicine and the incidence of PONV according to a standardized questionnaire on the first postoperative day. The administration of analgesic medicine was recorded until finishing the questionnaire.

In this study 5 pediatric outpatient operation groups (hernia repair n = 36, bone surgery n = 23, metal removal surgery n = 31, circumcision n = 65 and soft tissue surgery n = 49) and 9 pediatric inpatient operation groups (appendectomy n = 21, bone surgery n = 78, metal removal surgery n = 24, orchidopexy n = 31, combined operation (orchidopexy + hernia repair or circumcision) n = 14, otoplasty n = 9, tonsillectomy n = 41 and pectus excavatum surgery n = 6 and soft tissue surgery n=28) could be classified. All operation groups except the inpatient and outpatient soft tissue surgery groups received regional or infiltration anesthesia. Analgesic medicine was prescribed with the maximum permitted daily dose per kg body weight (paracetamol 100 mg/kgBW, metamizole 80 mg/kgBW, diclofenac 3 mg/kgBW and ibuprofen 40 mg/kgBW; in reserve tramadol 8 mg/kgBW and nalbuphine 2.4 mg/kgBW). The following operation groups complained of persistent pain (scale according to Hicks 0-10) and/or required more pain medicine (%): pediatric outpatients circumcision 5.1/19 %, pediatric inpatients appendectomy 6.5/43 %, tonsillectomy 6.4/32 %, pectus excavatum surgery 7.7/33 %, orchidopexy 4.2/19.4 %, otoplasty 3.1/22.2 %. The reason for the elevated postoperative pain was mainly insufficient administered pain medicine despite the prescription of the maximum daily dose per kg body weight or maybe due to a late administration. Circumcision/appendectomy/tonsillectomy/pectus excavatum surgery/orchidopexy/otoplasty (% of max. daily dose): paracetamol 5/58/99/36/57/37 %, metamizole 0,4/18/8/54/4/4 %, diclofenac 44/45/3/97/51/68 % or ibuprofen 42/1/0/0/0/0 %, tramadol 0,4/0/0/0/0/0 %, nalbuphine 0,4/1/16/0/2/0 %). As the standard inhalative general anesthesia and PONV prophylaxis with tropisetron (body weight: < 20 kg 1 mg, > 20 kg: 2 mg intravenous bolus) was performed. Dexamethasone (0.15-0.5 mg/kgBW, maximum allowed dose 8 mg intravenous bolus) was administered as a back-up drug for PONV. The nausea incidence was higher in the inpatient group (14-50 %) than in the outpatient group (10-29 %). The incidence of vomiting was higher in the inpatient (0-37 %) than in the outpatient group (3-17 %).

The quality analysis showed that especially children with the requirement for more pain medicine and a high PONV incidence (inpatient group) need further improvement in postoperative care. Because of small numbers in some operation groups this qualitative evaluation of the postoperative pain and PONV management only gives an approximate overview. The results of QUIPSi uncovered gaps in the postoperative pain management which will help improve the quality in the postoperative setting. The QUIPSi approach should be integrated as a daily tool into all pediatric surgical departments.