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Updated: Dec 31, 2025
Author Spotlight: Implementing the Enhanced Recovery After Surgery Concept in Rehabilitation Following Anterior Cruciate Ligament Reconstruction
Published on: March 1, 2024
Reducing postoperative nausea and vomiting in pediatric patients undergoing anterior cruciate ligament
Wallis T Muhly1, Theodore Ganley2, Ellen Jantzen1
1Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Insights
Implementing a standardized prophylaxis guideline significantly reduced postoperative nausea and vomiting (PONV) in patients undergoing anterior cruciate ligament reconstruction. This initiative lowered emesis rates and decreased opioid use, improving patient outcomes.
Area of Science:
- Anesthesiology
- Surgical Outcomes
- Patient Safety
Background:
- Postoperative nausea and vomiting (PONV) is a common complication after elective outpatient surgery, impacting patient recovery.
- Variability in PONV prophylaxis for anterior cruciate ligament reconstruction led to inconsistent patient outcomes.
- A standardized guideline was developed to address PONV variability in this surgical population.
Purpose of the Study:
- To implement a standardized PONV prophylaxis guideline for ambulatory anterior cruciate ligament reconstruction.
- To reduce the overall emesis rate to 5% or less.
- To improve patient experience and reduce complications associated with PONV.
Main Methods:
- A multidisciplinary team developed a PONV prophylaxis guideline including dexamethasone, ondansetron, low-dose propofol, nerve blocks, and ketorolac.
- Emesis rate was the primary outcome, tracked via P-chart.
- Process measures included medication adherence; balancing measures included opioid use, pain scores, and emergence time.
Main Results:
- Analysis of 817 patients (2014-2018) showed a baseline emesis rate of 17% that decreased to 5% post-guideline implementation.
- Perioperative opioid administration decreased, with the percentage of patients opioid-free increasing from 16% to 38%.
- The reduction in emesis rate was sustained over two years, indicating special cause variation.
Conclusions:
- Standardized PONV prophylaxis guidelines for outpatient anterior cruciate ligament reconstruction effectively lowered emesis rates.
- The observed reduction in PONV may be linked to the concurrent decrease in opioid administration.
- Implementing standardized care pathways improves surgical outcomes and patient safety.
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.
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