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Perioperative dexamethasone administration in tonsillectomy patients: A three-cycle audit showing improvement using printed theatre lists.

ABSTRACT: Dexamethasone administration prior to tonsillectomy has been shown to reduce morbidity and is part of SIGN guideline 117. We conducted a three-cycle audit of 149 patients to ascertain how well guidelines were being met and introduce a sustainable method to improve compliance. A 3-month audit was conducted to ascertain how many tonsillectomy patients didn't receive pre-operative dexamethasone. ENT secretaries were requested to add 'Dex Please' to tonsillectomy theatre lists. A 3-month re-audit was conducted; the intervention was only implemented in half of cases and so a reminding tool for the secretarial staff was administered before a third cycle. Initially, there was 73% compliance to SIGN guidelines, this improved to 87% in the second cycle. After the second intervention, all tonsillectomy theatre lists had the 'Dex Please' note and compliance to SIGN guidelines was 100%. There were five readmissions in the first cycle, three in the second and two in the third cycle. All readmissions were underdosed according to guidelines. Understanding there are regular staff rotations throughout many U.K. hospitals, we implemented a reliable method to increase compliance to guidelines which helped reduce post-operative readmission after tonsillectomy. This can be easily introduced to other institutions and for other perioperative requirements.

SUBMITTER: Bola S

PROVIDER: S-EPMC4695964 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Excessive or inadequate intravenous fluid given in the perioperative period can affect outcomes. A number of guidelines exist but these can conflict with the entrenched practice, evidence base and prescriber knowledge. We conducted a multi-centre audit of intraoperative and postoperative intravenous fluid therapy to investigate fluid administration practice and frequency of postoperative electrolyte disturbances.A retrospective audit was done in five hospitals of adult patients undergoing elective major abdominal, gastrointestinal tract or orthopaedic surgery. The type, volume and quantity of fluid and electrolytes administered during surgery and in 3 days postoperatively was calculated, and electrolyte disturbances were studied using clinical records.Data from four hundred thirty-one patients in five hospitals covering 1157 intravenous fluid days were collected. Balanced crystalloid solutions were almost universally used in the operating theatre and were also the most common fluid administered postoperatively, followed by hypotonic dextrose-saline solutions and 0.9 % sodium chloride. For three common uncomplicated elective operations, the volume of fluid administered intraoperatively demonstrated considerable variability. Over half of the patients received no postoperative fluid on day 1, and even more were commenced on free oral fluids immediately postoperatively or on day 1. Postoperative quantities of sodium exceeded the recommended amounts for maintenance in half of the patients who continued to receive intravenous fluids. Potassium administration in those receiving intravenous fluids was almost universally inadequate. Hypokalaemia and hyponatraemia were the common findings.We documented the current clinical practice and confirmed that early free oral fluids and cessation of any intravenous fluids is common postoperatively in keeping with the aims of enhanced recovery after surgery programmes. Excessive sodium and water and inadequate potassium in those given intravenous fluids postoperatively is common and needs to be investigated. The variation in intraoperative fluid volume administration for three common procedures is considerable and in keeping with other international studies. Future trials of fluid therapy should include the intraoperative and postoperative phases.

Project description:ImportancePractice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced.ObjectiveTo assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids.Design, setting, and participantsThis cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children.Main outcomes and measuresThe percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids.ResultsAmong 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications.Conclusions and relevanceThese findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.

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Perioperative dexamethasone administration in tonsillectomy patients: A three-cycle audit showing improvement using printed theatre lists.

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