An Analysis of Intravenous Versus Oral Analgesia on Postoperative Nausea and Vomiting in Children after Cranial Vault Remodeling

Background: Pediatric patients have a higher incidence of postoperative nausea and vomiting (PONV) compared to adults. NSAIDs and acetaminophen have been shown to be effective, safe alternatives to narcotics for the treatment of postoperative pain. This study sought to investigate the incidence of PONV after cranial vault remodeling using oral ibuprofen and acetaminophen versus intravenous ketorolac and acetaminophen.

Methods/Description: 50 consecutive patients (mean age 4.3 years  76%boys, 24%girls) undergoing cranial vault remodeling  were randomly assigned to either  a control group to be given only oral ibuprofen (10mg/kg) and acetaminophen (15mg/kg) or a treatment group given only intravenous ketorolac (0.5mg/kg) and acetaminophen (15mg/kg) postoperatively. PONV was assessed in a blinded fashion every hour for four hours, then every two hours for four hours, then every four hours during the remainder of the hospitalization. Patient assessments were performed by reviewing charts and direct patient, parent and nursing interviews. Number of vomiting episodes was recorded, as were episodes of nausea in children whose development permitted verbalization. Data was analyzed using T-Test, Chi-Square and Logistic Regressions analysis using SAS statistical software

Results: 28 patients randomized to the control group and 22 to the treatment group. There was no statistical differences among the groups with respect demographics, history of previous surgery, history of PONV, mean age at the time of surgery, weight, BMI, type of procedure (anterior vs. posterior cranial vault remodeling), EBL, captured cell saver amount, number of other medication doses postoperatively and length of stay. No patients received narcotics. Statistically significant differences in length of surgery were noted between groups, but not in total anesthesia duration. Statistically significant differences were found in the incidence of postoperative vomiting between groups (71.4% vs. 40.9 % p < 0.030), and also with postoperative nausea (85.7% vs.30 %, p < 0.005). In a multivariate logistic regression, controlling for age, BMI, and type of surgery, the odds ratio for vomiting in the control versus experimental groups was 3.61 (95% CI 1.11-11.76; p = 0.033), and for postoperative nausea was 14.0 (95% CI 1.40-71.69, p = 0.010). There were no intra/ postoperative complications in either group.

 

Conclusions: Intravenous use of ketorolac and acetaminophen postoperatively effectively reduces nausea and vomiting in children after cranial vault remodeling when compared to oral ibuprofen and acetaminophen.