Postoperative and post-discharge nausea may be very common in children, but it is woefully undertreated, according to a Baylor College of Medicine study. Researchers there concluded that use of the Baxter Retching Faces (BARF) scale may help stem the issue, as it is both easy to use and reliable in the clinical setting.
“Postoperative nausea and vomiting [PONV] is a major complication in adult anesthesia,” said Mehernoor F. Watcha, MD, associate professor of anesthesiology at the Houston-based institution. “But we tend to ignore nausea in children. Instead we focus on the vomiting and treat the patient then.” The situation is not helped by the fact that the severity of postoperative nausea is difficult to evaluate in children. “So we wanted to know if we can use the scale to measure the severity of nausea in pediatric patients, how feasible it is and how useful it is.”
To help answer these questions, Dr. Watcha and his colleagues enrolled 327 children undergoing general anesthesia into the trial; each received clinically indicated prophylactic antiemetics. “Note that we did not change anesthetic practices at all in the study,” Dr. Watcha said. “Everybody was allowed to administer what they felt was appropriate.”
Patients rated the severity of their nausea at various time points before the surgery, in the PACU, and after discharge phases using the BARF scale and a 10-point visual analog scale (VAS). Patients also rated the change in their degree of nausea at different time points using a 5-point Likert scale. Emetic episodes and rescue therapy administration also were recorded.
As Dr. Watcha reported at the 2016 annual meeting of the International Anesthesia Research Society (abstract S-246), 34.9% of children saw their nausea scores increase from preoperative values, with severe nausea (≥7) occurring in 4.9%. PACU emesis occurred in 4.3% of patients, with severe vomiting (at least three episodes) in 0.3%. Of note, rescue antiemetics were given to only 2.8% of children.
“If you compare this with published data in adults,” Dr. Watcha said, “we see that the incidence of postoperative nausea is significantly higher in children than adults, while the rate of emesis is about the same between them. But the administration of antiemetics in the PACU is much lower in children.” Dr. Watcha referred to the adult nausea study of Apfel et al (Anesthesiology 2012;117:475-486; Table).
BARF Scale Effective For Most Kids
“Then we followed up to see what happens to these children after they go home,” Dr. Watcha continued. Follow-up diaries from 220 patients documented post-discharge nausea in 30.9% of children, with severe nausea affecting 12.3%, vomiting in 9.1% and severe emesis in 2.3%. Dr. Watcha noted that 10 of the 48 children (20.8%) who were younger than 5 years of age did not understand how to use the BARF scale and VAS. By comparison, all of those at least 5 years of age could use the scales.
“In summary, we found that this BARF scale is easy and feasible to use in children ages 5 years and older,” Dr. Watcha said. “Equally important, we’ve demonstrated that children have nausea in the PACU, but for some reason, they’re not being treated. We’ve also demonstrated that the nausea is not just limited to the OR [operating room] and PACU; it also occurs following discharge.”
Given the facility with which the BARF scale can be administered, Dr. Watcha recommended its use in children. “We’ve shown that postoperative nausea is a problem, and we can measure the severity of that problem in children for the cost of just a few cents to print a piece of paper,” he said. “So I would suggest we should be using the BARF scale regularly in the PACU.”
Dr. Watcha’s audience agreed that preventing and treating PONV in children is a laudable goal, but they wondered whether its diagnosis would affect throughput in outpatients. “I wonder if the diagnosis of severe nausea might lead the patient to an unexpected admission,” said Denis H. Jablonka, MD, assistant professor of clinical anesthesiology and critical care at the Children’s Hospital of Philadelphia. “My feeling is that it can lead to readmissions.”
“I can tell you this,” Dr. Watcha replied. “If you don’t ask them if they have nausea, no patient is going to be admitted for nausea. Just like if you don’t ask them if they’re having pain, no patient is going to be admitted for pain.”
“It seems to me that the whole point of outpatient surgery is about saving money,” commented Myron Yaster, MD, the Richard J. Traystman Distinguished Professor of Anesthesiology/Critical Care Medicine and Pediatrics at the Johns Hopkins University School of Medicine, in Baltimore. “Sure, it would be much easier for the patient if they got to stay in the hospital, but the current economic climate in health care doesn’t allow for that.”
Undeterred, Dr. Watcha plans to continue his research into the benefits of using the BARF scale in pediatric patients. “Now that I have these data, my next step is to design a study showing that if you start treating children who have nausea in the PACU, does that improve the quality of their recovery?”