B R I E F H O S P I T A L ADMISSIONS FOR PEDIATRIC STRABISMUS SURGERY STEPHEN M. WEINSTOCK, M.D.,
AND J O H N T. FLYNN,
M.D.
Miami, Florida The policy of performing certain elective pediatric surgical procedures on patients admitted briefly to the hospital has been the subject of recent reports.1*4 These have been concerned with nonophthalmic surgical pro cedures. Others5"11 have been concerned with the psychological factors involved in hos pitalizing the child with strabismus. This is a retrospective study of strabismus surgery performed on children who were outpatients from March 1971 to July 1973. We included all those operated on as outpatients, clinic as well as private patients. PATIENTS AND METHODS
We reviewed the charts of 170 consecutive patients who underwent strabismus surgery on an outpatient basis. No patients were ex cluded from the study for any reason. The charts were analyzed for the following fac tors: age, diagnosis, type of surgery, preoperative medication, type of anesthesia, anesthetic time (defined as the time between the induction of general anesthesia and extubation), recovery time (defined as the time between extubation and discharge from the hospital), and complications during induc tion, anesthesia, or recovery. We sent a questionnaire to the parents of all children. We attempted to tabulate the postoperative complications that ensued within the first 48 hours after-surgery and that constituted part of the morbidity of the procedure. We From the Bascom Palmer Eye Institute, Departnent of Ophthalmology, University of Miami school of Medicine, and Jackson Memorial Hos)ital, Miami, Florida. This study was supported in >art by the Miami Beach Lions Club, and in part >y the Heed Ophthalmic Foundation, Inc. (Dr. Afeinstock). Reprint requests to John T. Flynn, M.D., 1638 ■J.W. 10th Ave., Miami, FL 33136.
also used this questionnaire to determine whether the parents had accepted their role in postoperative care. The success or failure of the various surgical procedures was not analyzed in this report. Outpatient surgical routine—Surgery done on an outpatient requires few departures from the normal routine. Since such sur gery was performed on Mondays only, the patients scheduled for surgery were seen in the clinic on Friday afternoon before the op eration. History taking and physical ex amination were performed, blood and urine samples were drawn, and routine administra tive procedures were completed. On Sunday morning the patients returned to the clinic and were examined by the anesthesiologists and ophthalmologists. At 6:45 AM on Mon day, parents and child were assigned to a room on the general pediatric floor that served as a waiting and recovery room. No more than three patients and their parents were assigned to the same room. Surgery commenced at 8 AM and patients were operated on in order of increasing age. A nurse familiar with recovery room tech niques supervised and was equipped with oxygen, suction, resuscitating drugs and equipment, and a telephone. After surgery and extubation, the child was returned to this room. When the nurse considered the child awake and ready for discharge, mem bers of the ophthalmology and anesthesiology services examined and discharged the child. Parents were advised about possible serosanguineous drainage from the eye and on the eye pad; they were given aspirin and an antiemetic suppository; they were in structed in the use of simple arm restraints in smaller infants where necessary. The first follow-up visit was at 8 AM the next morn ing.
525
526
AMERICAN JOURNAL OF OPHTHALMOLOGY TABLE 1 DATA ON PATIENT POPULATION
Total No. Male/Female Age Mean Range Diagnoses Esotropia Exotropia Strabismus repair Primary Reoperations
170 84/86 S.8 yrs 5 mos-18 yrs 122 48 170 (151) (19)
RESULTS
Patient population—The mean age of the patients was about 6 years (Table 1). We have avoided this type of hospitalization in older children because their size makes it difficult to restrain them under the limited recovery room circumstances should they have a stormy postoperative recovery period. Now the age limit is 10 years. We performed typical strabismus repair. Types of anesthesia—Although surgery was performed on an outpatient basis, most patients received the same type and dosage of preoperative medication as inpatients (Table 2). We preferred mask as the usual method of induction of anesthesia to the trauma of a needle puncture. For the oc casionally objecting child, we administered a small dose of intravenous thiopental so dium (Pentothal). In all cases the airway was maintained via endotracheal intubation. A combination of halothane, nitrous oxide, TABLE 2
and oxygen was used as the anesthetic agent in all cases. Anesthesia averaged 91 minutes (Table 3). This may seem long, but two factors account for this: First, this was a teaching situation involving both anesthesiology and ophthalmology residents. Second, 32% of the muscle procedures were per formed on three or more muscles and 11% were reoperations. The few anesthesia com plications (Table 4) occurred from traction on the rectus muscle during surgery.12 No greater risk of intraanesthesia complications seemed to exist for the outpatient as com pared with hospitalized patients. Anesthetic variables—Several factors af fecting the course of surgery on an outpa tient basis may be partially controlled by the surgeon-anesthesiologist team. We tabulated data on the incidence of various preopera tive medication regimens and the length of exposure to anesthetic gases against the occurrence during postoperative recovery of nausea, vomiting, drowsiness, eye pain, cough, croup, and chest pain. To determine the influence of each factor on the incidence of these postoperative symptoms, we per formed many chi-square tests using these data.13 Of these, only the type of preopera tive medication used caused postoperative vomiting in a manner that differed sig nificantly from chance (Table 5). Atropine alone was accompanied by less nausea anc vomiting than any other anesthetic drug em ployed. With this regimen, less than one child in five was likely to have postoperative vomiting, while the addition of agents sucl as a narcotic, barbiturate, or tranquilizer in
PREOPERATIVE MEDICATION
Medication Atropine Atropine and meperidine Atropine and pentobarbital* Atropine and meperidinef None
SEPTEMBER. 1975
TABLE 3
No. of Patients
%of Total
31 107 10 18 4
18 63 6 11 2
* Diazepam or droperidol occasionally used in stead of pentobarbital. t Pentobarbital, or secobarbital, or diazepam used occasionally instead of meperidine.
DURATION OF ANESTHESIA
Range Average
Time, min
No. of Patients
- 60 75 90 120 +120 40-170 91
6 33 49 67 IS
527
VOL. 80, NO. 3, PART II PEDIATRIC STRABISMUS SURGERY
creased the risk of postoperative vomiting. With the vomiting there is a risk of aspira tion, and postoperative vomiting was an im portant reason for parental dissatisfaction with the scheme of surgery on outpatients. Other trends in our data did not reach the level of statistical significance. For ex ample, patients receiving atropine alone seemed more likely to require aspirin for postoperative pain (the only analgesic used in this study) than if they had received meperidine (Demerol) or a barbiturate be fore anesthesia; and prolonged drowsiness seemed to occur more frequently in patients who ingested atropine and either a barbitu rate or a narcotic rather than atropine alone. Recovery time—Our anticipation was that prolonged recovery would be associated with the longer surgical procedures. This was not the case. The statistical data seemed to show a wide range of recovery time that averaged about four hours. When we examined the data more closely, we found that a factor governing the length of recovery time was the availability of the physician to observe the patient after surgery. This meant that patients who were operated on early in the day waited until the surgeon and anesthesi ologist completed all scheduled operations, although the patients might be awake and ready for discharge. In cojatrast, those op erated on later in the day;': ha
AND J O H N T. FLYNN,
M.D.
Miami, Florida The policy of performing certain elective pediatric surgical procedures on patients admitted briefly to the hospital has been the subject of recent reports.1*4 These have been concerned with nonophthalmic surgical pro cedures. Others5"11 have been concerned with the psychological factors involved in hos pitalizing the child with strabismus. This is a retrospective study of strabismus surgery performed on children who were outpatients from March 1971 to July 1973. We included all those operated on as outpatients, clinic as well as private patients. PATIENTS AND METHODS
We reviewed the charts of 170 consecutive patients who underwent strabismus surgery on an outpatient basis. No patients were ex cluded from the study for any reason. The charts were analyzed for the following fac tors: age, diagnosis, type of surgery, preoperative medication, type of anesthesia, anesthetic time (defined as the time between the induction of general anesthesia and extubation), recovery time (defined as the time between extubation and discharge from the hospital), and complications during induc tion, anesthesia, or recovery. We sent a questionnaire to the parents of all children. We attempted to tabulate the postoperative complications that ensued within the first 48 hours after-surgery and that constituted part of the morbidity of the procedure. We From the Bascom Palmer Eye Institute, Departnent of Ophthalmology, University of Miami school of Medicine, and Jackson Memorial Hos)ital, Miami, Florida. This study was supported in >art by the Miami Beach Lions Club, and in part >y the Heed Ophthalmic Foundation, Inc. (Dr. Afeinstock). Reprint requests to John T. Flynn, M.D., 1638 ■J.W. 10th Ave., Miami, FL 33136.
also used this questionnaire to determine whether the parents had accepted their role in postoperative care. The success or failure of the various surgical procedures was not analyzed in this report. Outpatient surgical routine—Surgery done on an outpatient requires few departures from the normal routine. Since such sur gery was performed on Mondays only, the patients scheduled for surgery were seen in the clinic on Friday afternoon before the op eration. History taking and physical ex amination were performed, blood and urine samples were drawn, and routine administra tive procedures were completed. On Sunday morning the patients returned to the clinic and were examined by the anesthesiologists and ophthalmologists. At 6:45 AM on Mon day, parents and child were assigned to a room on the general pediatric floor that served as a waiting and recovery room. No more than three patients and their parents were assigned to the same room. Surgery commenced at 8 AM and patients were operated on in order of increasing age. A nurse familiar with recovery room tech niques supervised and was equipped with oxygen, suction, resuscitating drugs and equipment, and a telephone. After surgery and extubation, the child was returned to this room. When the nurse considered the child awake and ready for discharge, mem bers of the ophthalmology and anesthesiology services examined and discharged the child. Parents were advised about possible serosanguineous drainage from the eye and on the eye pad; they were given aspirin and an antiemetic suppository; they were in structed in the use of simple arm restraints in smaller infants where necessary. The first follow-up visit was at 8 AM the next morn ing.
525
526
AMERICAN JOURNAL OF OPHTHALMOLOGY TABLE 1 DATA ON PATIENT POPULATION
Total No. Male/Female Age Mean Range Diagnoses Esotropia Exotropia Strabismus repair Primary Reoperations
170 84/86 S.8 yrs 5 mos-18 yrs 122 48 170 (151) (19)
RESULTS
Patient population—The mean age of the patients was about 6 years (Table 1). We have avoided this type of hospitalization in older children because their size makes it difficult to restrain them under the limited recovery room circumstances should they have a stormy postoperative recovery period. Now the age limit is 10 years. We performed typical strabismus repair. Types of anesthesia—Although surgery was performed on an outpatient basis, most patients received the same type and dosage of preoperative medication as inpatients (Table 2). We preferred mask as the usual method of induction of anesthesia to the trauma of a needle puncture. For the oc casionally objecting child, we administered a small dose of intravenous thiopental so dium (Pentothal). In all cases the airway was maintained via endotracheal intubation. A combination of halothane, nitrous oxide, TABLE 2
and oxygen was used as the anesthetic agent in all cases. Anesthesia averaged 91 minutes (Table 3). This may seem long, but two factors account for this: First, this was a teaching situation involving both anesthesiology and ophthalmology residents. Second, 32% of the muscle procedures were per formed on three or more muscles and 11% were reoperations. The few anesthesia com plications (Table 4) occurred from traction on the rectus muscle during surgery.12 No greater risk of intraanesthesia complications seemed to exist for the outpatient as com pared with hospitalized patients. Anesthetic variables—Several factors af fecting the course of surgery on an outpa tient basis may be partially controlled by the surgeon-anesthesiologist team. We tabulated data on the incidence of various preopera tive medication regimens and the length of exposure to anesthetic gases against the occurrence during postoperative recovery of nausea, vomiting, drowsiness, eye pain, cough, croup, and chest pain. To determine the influence of each factor on the incidence of these postoperative symptoms, we per formed many chi-square tests using these data.13 Of these, only the type of preopera tive medication used caused postoperative vomiting in a manner that differed sig nificantly from chance (Table 5). Atropine alone was accompanied by less nausea anc vomiting than any other anesthetic drug em ployed. With this regimen, less than one child in five was likely to have postoperative vomiting, while the addition of agents sucl as a narcotic, barbiturate, or tranquilizer in
PREOPERATIVE MEDICATION
Medication Atropine Atropine and meperidine Atropine and pentobarbital* Atropine and meperidinef None
SEPTEMBER. 1975
TABLE 3
No. of Patients
%of Total
31 107 10 18 4
18 63 6 11 2
* Diazepam or droperidol occasionally used in stead of pentobarbital. t Pentobarbital, or secobarbital, or diazepam used occasionally instead of meperidine.
DURATION OF ANESTHESIA
Range Average
Time, min
No. of Patients
- 60 75 90 120 +120 40-170 91
6 33 49 67 IS
527
VOL. 80, NO. 3, PART II PEDIATRIC STRABISMUS SURGERY
creased the risk of postoperative vomiting. With the vomiting there is a risk of aspira tion, and postoperative vomiting was an im portant reason for parental dissatisfaction with the scheme of surgery on outpatients. Other trends in our data did not reach the level of statistical significance. For ex ample, patients receiving atropine alone seemed more likely to require aspirin for postoperative pain (the only analgesic used in this study) than if they had received meperidine (Demerol) or a barbiturate be fore anesthesia; and prolonged drowsiness seemed to occur more frequently in patients who ingested atropine and either a barbitu rate or a narcotic rather than atropine alone. Recovery time—Our anticipation was that prolonged recovery would be associated with the longer surgical procedures. This was not the case. The statistical data seemed to show a wide range of recovery time that averaged about four hours. When we examined the data more closely, we found that a factor governing the length of recovery time was the availability of the physician to observe the patient after surgery. This meant that patients who were operated on early in the day waited until the surgeon and anesthesi ologist completed all scheduled operations, although the patients might be awake and ready for discharge. In cojatrast, those op erated on later in the day;': ha
