Implementing a protocol to reduce postoperative nausea and vomiting (PONV) following laparoscopic appendectomy has been found to be effective at facilitating same-day discharges, according to investigators in Ohio.
The study tracked a quality improvement (QI) project conducted at Nationwide Children’s Hospital, in Columbus, over a 12-month period. The investigators initially developed and implemented a protocol to understand and ameliorate the factors that contribute to or hinder same-day discharge following laparoscopic appendectomy procedures.
Following the implementation of the initial protocol, they discovered that PONV contributed to the prevention of same-day discharge in 38.1% of cases over a six-month period. The anesthesiology and surgery departments then collaborated on the development of a perioperative QI protocol focused on reducing the incidence of PONV and increasing the rate of same-day discharges.
The protocol was posted on the walls of the general surgery operating rooms of the hospital (Table). Electronic medical records alerted providers when to use the protocol and to note when the procedure was in fact a simple appendectomy, without complications such as a rupture.
| Table. Simple Laparoscopic Appendectomy Anesthesia Protocol |
| Preoperative |
| · Midazolam 0.05-0.1 mg/kg (maximum 2 mg), as needed
· Fluid load: 10 mL/kg |
| Induction |
| · Lidocaine 1 mg/kg
· Propofol 2-3 mg/kg · Fentanyl 2-3 mcg/kg · NMBA: Succinylcholine, rocuronium, vecuronium or cisatracurium for RSI · Small doses of non-depolarizing NMBA as needed for intraoperative muscle relaxation |
| Maintenance |
| · Fluid load: additional 10-20 mL/kg
· Local infiltration of all port sites by surgeon or TAP block by anesthesiology · Dexamethasone 0.1 mg/kg (maximum 4 mg) · Ondansetron 0.15 mg/kg (maximum 8 mg) · Desflurane titrated to BIS 40-60 · Dexmedetomidine 0.5-1 mcg/kg over 5 minutes · Acetaminophen 15 mg/kg (maximum 1,000 mg) · Lidocaine 1 mg/kg every 1 hour |
| Emergence |
| · Reversal of neuromuscular blockade (slowly)
· Hydromorphone 2-3 mcg/kg increments as needed · Ketorolac 0.5 mg/kg IV (maximum dose 30 mg) at end of case pending surgeon approval |
| BIS, bispectral index; NMBA, neuromuscular blocking agent; RSI, rapid sequence induction; TAP block, transversus abdominis plane block |
More Same-Day Discharges
In the six months after the implementation of the protocol, the investigators saw PONV as a factor preventing same-day discharge drop from 38.1% to 12.9% of cases (from 16/42 to 8/62; P=0.004). They also observed a trend toward increased same-day discharges in cases that were completely compliant with the protocol compared with those in which three or more items were not followed, but this difference was not statistically significant (72% vs. 59%; P=0.106). The rate of compliance with all of the items was 30%; the most common reasons for noncompliance were failure to administer dexmedetomidine and using desflurane as the volatile anesthetic agent, which often required replacing the vaporizer in the anesthesia machine.
Giorgio Veneziano, MD, program director of the pediatric regional anesthesia fellowship at Nationwide Children’s, who led the study, said the initial goal of the project was to achieve full compliance with the protocol in at least 50% of patients, and that he and his colleagues are still working toward that goal.
“We’re continuing to increase compliance. We’ve initiated a new feedback mechanism wherein anesthesia providers who have done these simple laparoscopic appendectomy cases get an email each week with feedback on how they did,” Dr. Veneziano said. “It’ll say ‘good job, you were compliant,’ or ‘here are the pieces that were missing in these patients.’”
He also noted that the protocol has been amended since these findings were presented, to change the method of reversal of neuromuscular blockade from neostigmine/glycopyrrolate to sugammadex, because neostigmine has been associated with increased rates of PONV.
Dr. Veneziano said his team is continuing to monitor same-day discharge rates to see if the observed improvement continues. “If we reach statistical significance with overall same-day discharge rates, this is certainly something I’d recommend to other institutions. But I think institutions have to look at their own rates of PONV for these particular cases and see if it’s something that makes sense for them.”
Franklyn Cladis, MD, associate professor of anesthesiology at the University of Pittsburgh and program director of the pediatric anesthesiology fellowship at Children’s Hospital of Pittsburgh, said this study reflects a broader and beneficial national trend toward standardizing care in this area.
“We have a protocol that’s similar to this for teenagers that come to the hospital for laparoscopic cholecystectomy, to try to get them on the launch pad to go home the same day,” Dr. Cladis said. “There are two big differences: One is we added a scopolamine patch, because if you look at the literature, the No. 1 thing that keeps kids from going home is PONV, just like they observed here.
“I think dexmedetomidine is a good adjunct for anesthesia, but we have observed that some kids are too sedated when they got 0.5 to 1 mcg/kg of dexmedetomidine,” he said. “That could delay discharge if you’re trying to go home the same day. We reduced our dose of dexmedetomidine by 50% in our laparoscopic cholecystectomy patients to minimize the sedation.”
Dr. Cladis also said he would like to see more studies like this one take place. “I think the process they went through, doing a QI project, is very important. It moves toward standardizing care in a way that’s evidence based in an effort to provide the best care possible as consistently as possible. That’s important.”
The findings were originally presented at the 2017 meeting of the Society for Pediatric Anesthesia/American Academy of Pediatrics Section on Anesthesiology and Pain Medicine (abstract NM-181).