My first thought was ‘I need a drink.’ – Daniel Craig
In children, particularly those under the age of four, it can be very difficult to distinguish the exact cause of their post-operative distress. It can be emergence delirium, pain, thirst and hunger, or something else. This can lead to misdiagnosis and mistreatment.
This study posed two questions
- Does early fluid postoperatively influence the use of opiod analgesics after paediatric day case surgery
- Does early fluid postoperatively influence the incidence of post operative vomiting (POV) after paediatric day case surgery
This study was a randomised placebo controlled trial and 231 patients were ultimately included in the analysis.
The participants were aged from six months to four years and the study ran between Sept 2013-2014.
The study included a variety of day case surgical cases and was done in a hospital in France.
Participants were excluded if there was any underlying pathology predisposing to POV or if there were any anaesthetic and surgical concerns which could prevent early oral intake.
The participants were randomized by a computer into the liberal group (i.e. Intervention group) or to the control group. The number which referred to which they group they belonged to, was contained within a sealed envelope which was opened by staff independent to the study in PACU. At this point, blinding was broken.
The liberal group, who scored >4 on the FLACC (Face Legs Activity Crying Consolability sore) scoring system, was offered received 10ml/kg apple juice (referred to as subgroup 1); if they refused to juice, they received opioids instead, according to hospital protocol (referred to as subgroup 2).
The control group was given opioids again according to hospital protocol (2mg/kg nalbuphine or morphine) and titrated to effect.
As well as recording the incidence of vomiting post operatively in PACU and on the ward, the study also recorded if ondansetron was given on the 2nd incidence of POV and if any prophylactic anti-emetic was given intra-op (dexamethasone/droperidol) if POVOC score was ≥3.
The parents were given a questionnaire to complete for 3 days post discharge and the results were followed up by staff via a phone call.
The study’s primary outcome was the incidence POV during first 3 days post surgery and they secondary outcomes were length of PACU stay, dose of opioid, number of POV episodes, post op adverse effects (desaturation, difficult swallowing)
The study reported a reduction in the incidence of POV from 24% in the control group down to 11% in the liberal group (p=0.006), with reduction on PACU stay from 65 mins down to 53 mins in the control and liberal group respectively (p-0.002). They also found a reduction in the use of opiods from 36% in the control group down to 14% in the liberal group (p=0.001).
Although this study was randomised, it was un-blinded and stopped early for reasons which weren’t really clarified in their discussion. It carried a higher incidence of POV than that found in a study previous carried out by that hospital and on which this study’s statistics (sample size, power etc) was based on.
They admitted to being unable to distinguish causes of maladaptive post anaesthesia behaviour in PACU. They also accepted that several may have refused to drink as they may not have liked apple juice.
In terms of the subgroups, there was quite a lot of variations in characteristics between subgroups 1 & 2 , in particular the male to female ratio (more males in subgroup 1), less intraoperative fluids given to subgroup 1 and longer fasting times in subgroup 2.
Although it was an original study, ultimately, all it proved was that by not giving children opiates in PACU, the incidence of POV was reduced.
Summary by Dr Penny Bantanidis
Second Opinion: Have a look at what the Welsh trainees thought of this paper