Understanding anesthesia's role in the unplanned admission of pediatric ambulatory surgical patients
Mackenzie, Matthew Robert
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Introduction: Pediatric ambulatory surgery has experienced a surge in popularity as new surgical and anesthetic techniques have made it a more viable option for a host of surgical procedures. While the vast majority of patients are successfully discharged upon recovery from anesthesia, a small proportion 1-2.5% in previous studies must be admitted to the hospital's inpatient unit. Many of these patients present with conditions such as uncontrollable post-operative pain and nausea and vomiting associated with anesthesia. As such we sought to characterize the unplanned admissions population at Children's Hospital Boston, a tertiary care pediatric hospital and investigate Anesthesia's role in their care. Methods: Patients were identified as possible candidates for inclusion into this study if they experienced a status change in the Children's Hospital Boston records system from "Day Surgery Unit" to "Inpatient Unit". Data from these patients was gathered using Anesthesia records, medical record number summaries, growth charts, and other electronic medical records. Results: The unplanned admission rate at Children's Hospital Boston was 1.29% from January 2010 through June 2011, representing 347 patients from a day surgery population of 26,951. No statistically significant differences were observed in regards to patient fitness, as measured by American Association of Anesthesiologist classification, when compared to patients successfully discharged. The leading causes of admission were uncontrollable postoperative pain (n=117, 39.8%) and post-operative nausea and vomiting (n=94, 32.0%). When compared to the successfully discharged patient population; orthopedic surgery experienced a statistically significant increase in its contribution rate while genitourinary surgery experienced a statistically significant decrease. Pre-operative acetaminophen usage was only 19%, while midazolam pre-medication was 51.4%. Regional anesthesia was utilized in only 11.5% of cases overall and 27.3% of orthopedic patients. Patients experiencing post-operative nausea and vomiting were primarily treated with ondansetron and dexamethasone as prophylaxis while overwhelmingly receiving a re-dosing of ondansetron post operatively. Post-operative utilization of metaclopramide in these patients was 3.7%. Conclusion: At Children's Hospital Boston 71.8% of unplanned admissions are either for pain or nausea and vomiting, two conditions that are intimately related. It is reasonable to presume that an increased emphasis on prophylaxis analgesia in the form of pre-operative acetaminophen and regional anesthesia would help alleviate a portion of these cases directly related to uncontrollable pain. It is also not unreasonable to assume that these options may decrease post-operative opioid usage, a significant risk factor for post-operative nausea and vomiting. In cases where nausea and vomiting is still present and patients have received ondansetron and dexamethasone intraoperatively, there seems to be a reliance on re-dosing with ondansetron, whereas based on physiological pathways of nausea patients, a third drug-class may be a better option. Improvements in these areas could decrease the unplanned admission rate at Children's Hospital Boston.
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