Early postoperative oral fluid intake in paediatric day case surgery influences the need for opioids and postoperative vomiting: a controlled randomized trial

British Journal of Anaesthesia. 2017;118(3): 407-414

Presented by: Dr T. Sheppard

Background

  • Assessing young children in recovery is difficult and challenging
  • Distress post-operatively is multi-factorial
  • With children too young to communicate effectively, inappropriate treatments can be given

Design & Setting

  • Prospective randomised controlled trial
  • Placebo-controlled
  • Day case paediatric surgery
  • Wide variety of surgery types

Subjects

  • Ages 6m-4yr
  • ASA 1-3
  • GA (Day surgery)

Exclusion criteria

  • Surgery constraining post operative fluid intake
  • Known digestive pathology pre-disposing to POV
  • Enrolment in another study

Intervention

Randomised to 2 groups

  1. Liberal group (offered 10ml/kg apple juice post op)
  • FLACC score ≥4 (Face Legs Activity Crying COnsolability sore)
  • Apple juice offered
  1. Control group (protocolised opioid administration)
  • Opioid given as per unit protocol
  • 2mg/kg nalbuphine
  • Morphine titrated to effect

Also recorded:

  • Number & location of POV (i.e. in PACU/on ward)
  • Ondansetron given on 2nd incidence of POV
  • Prophylactic anti-emetic (dexamethasone/droperidol) if POVOC ≥3

Outcomes

Primary outcome: global incidence of post-operative vomiting during first 3 days after surgery (aim to include delayed POV)

Secondary outcome

  • Total dose opioid analgesics in PACU
  • Length of PACU stay
  • Number of episodes POV in PACU/on ward/on 1st and 3rd post-op days
  • Post-operative adverse events e.g. difficulty swallowing/desaturation

Results

 

Use of opioid post-op

Post operative vomiting PACU stay duration
Liberal group

14.04%

11.4%

53.45 minutes

Control group

35.9%

23.93%

65.05 minutes

  p=0.001 p=0.006

p=0.002

Further split into subgroups

  • Subgroup 1: children randomised as liberal, FLACC score ≥4, accepted apple juice
  • Subgroup 2: children randomised as liberal, FLACC score ≥4, refused drink AND controls
  • Subgroup 1 vs 2: significantly less POV in subgroup 1

Conclusion

If apple-juice offered:

  • Significant reduction in incidence of post-operative vomiting
  • Significant reduction in use of post-op opioids
  • Significant reduction in recovery stay

Strengths

  1. Original study
  2. Randomised controlled trial
  3. Standardised anaesthetic technique
  4. Including pre-med & paracetamol
  5. Prophylactic anti-emetic according to protocol (anaesthetist blinded)
  6. 93-97% use of N2O

Weaknesses

  1. Un-blinded
  2. Study stopped early
  3. Higher incidence of POV in children in this study than previous audit carried out before study completed
  4. Unable to distinguish causes of maladaptive post anaesthesia behaviour
  5. Variations in subgroups 1 & 2
  • Male:female ratio – more males in subgroup 1
  • Less intraoperative fluids given to subgroup 1
  • Fasting times

Implications

  1. This study suggests that early re-instatement of oral fluids significantly reduces incidence of post-operative vomiting
  2. Potential for reduction in opioid use post-op

Potential for Impact

  • Impact of fasting times: 11.3hr pre-op seems excessively long for day case paediatric surgery
  • Could increase list efficiency due to shorter time in recovery
  • Risk assess for use of prophylactic anti-emetic
  • Using standardised criteria for POV in children
  • Should we be prescribing apple juice? Concentrate or pressed? Does it need to be apple juice? Would water be sufficient and have the same effect?