Background: Post-operative nausea and vomiting is a significant cause of morbidity in pediatric anesthesia. As well as patient discomfort, post-operative nausea and vomiting can also result in dehydration, delayed discharge and unplanned hospital admission. Children undergoing strabismus surgery are known to be a particularly high risk group for post-operative nausea and vomiting. Aims:The aim of this project was to reduce post-operative nausea and vomiting by 50% over a period of 12 months. Methods:This was a single centre retrospective observational study, with prospective observational follow up. A driver diagram was constructed and smart aim established. The Plan-Do-Study-Act method of quality improvement was used for this project. Benchmark data from one hundred patients was collected retrospectively from patient records. After this, interventions were introduced and serial data was prospectively collected. Statistical process control charts were constructed to monitor percentage bundle compliance and incidence of post-operative nausea and vomiting in the post anesthetic care unit.Results: Post-operative nausea and vomiting data was collected for 1079 children in total. Baseline incidence of post-operative nausea and vomiting was 18%. After 4 years this was reduced to 4.72%. At the conclusion of the project there was no significant difference over the previous six months between the incidence of postoperative nausea and vomiting in the strabismus population and the general post anesthetic care unit population.Conclusion: Using quality improvement methodology, we were able to sustainably reduce the incidence of post-operative nausea and vomiting for children undergoing strabismus repair. We demonstrated using an evidence based therapeutic bundle can reduce incidence of post-operative nausea and vomiting in the high risk surgical strabismus population to a level comparable to the average post-operative nausea and vomiting incidence in our post anesthetic care unit population. K E Y W O R D Sbundle, nausea, pediatric, quality, strabismus, vomiting | 691 ALI et AL.
Background: Postoperative pain is a significant cause of morbidity in pediatric anesthesia, which can result in delayed discharge and unplanned hospital admission.Children undergoing strabismus surgery are known to be a particularly high-risk group for postoperative pain.Aim: The aim of this project was to reduce the incidence of moderate to severe postoperative pain by 25% over a period of 12 months in children undergoing strabismus surgery. Methods:This was a multidisciplinary quality improvement project using the Institute for Healthcare Improvement model for improvement and iterative Plan-Do-Study-Act cycles. Baseline data from one hundred patients were collected retrospectively from patient records. Subsequently, iterative interventions introduced comprised: a perioperative bundle (comprising preoperative acetaminophen, intraoperative dexamethasone and ketorolac, a long-acting opioid, and two anti-emetics), email reminders, dissemination of results at departmental rounds, and an intraoperative clinical decision aide. Postoperative pain data were collected as an outcome measure, and length of stay in PACU was monitored as a balancing measure. Statistical process control charts were constructed to monitor bundle compliance and incidence of postoperative pain in the postanesthesia care unit.
BACKGROUND: No evidence currently exists to quantify the risk and incidence of perioperative respiratory adverse events (PRAEs) in children with sleep-disordered breathing (SDB) undergoing all procedures requiring general anesthesia. Our objective was to determine the incidence of PRAEs and the risk factors in children with polysomnography-confirmed SDB undergoing procedures requiring general anesthesia. METHODS: Retrospective review of all patients with polysomnography-confirmed SDB undergoing general anesthesia from January 2009 to December 2013. Demographic and perioperative outcome variables were compared between children who experienced PRAEs and those who did not. Generalized estimating equations were used to build a predictive model of PRAEs. RESULTS: In a cohort of 393 patients, 51 PRAEs occurred during 43 (5.6%) of 771 anesthesia encounters. Using generalized estimating equations, treatment with continuous positive airway pressure or bilevel positive airway pressure (odds ratio, 1.63; 95% confidence interval [CI], 1.05–2.54; P = .031), outpatient (odds ratio, 1.37; 95% CI, 1.03–1.91; P = .047), presence of severe obstructive sleep apnea (odds ratio, 1.63; 95% CI, 1.09–2.42; P = .016), use of preoperative oxygen (odds ratio 1.82; 95% CI, 1.11–2.97; P = .017), history of prematurity (odds ratio, 2.31; 95% CI, 1.33–4.01; P = .003), and intraoperative airway management with endotracheal intubation (odds ratio, 3.03; 95% CI, 1.79–5.14; P < .001) were associated with PRAEs. CONCLUSIONS: We propose the risk factors identified within this cohort of SDB patients could be incorporated into a preoperative risk assessment tool that might better to identify the risk of PRAE during general anesthesia. Further investigation and validation of this model could contribute to improved preoperative risk stratification, decision-making (postoperative admission and level of monitoring), and health care resource allocation.
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