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A1021
October 22, 2016
10/22/2016 7:30:00 AM - 10/22/2016 9:00:00 AM
Room W476
Transition From Hospital to Home for Ambulatory Pediatric Orthopedic Patients With Regional Anesthesia: Pain and Functional Recovery Assessed in the Post-discharge Period
J. William Sparks, M.D., Cornelius A. Sullivan, M.D., Karen R. Boretsky, M.D.
Boston Children's Hospital, Wellesley, Massachusetts, United States
Disclosures:  J. Sparks: None. C.A. Sullivan: None. K.R. Boretsky: G. Consulting Fees; Self; Analogic Inc.
Introduction: Painful orthopedic surgery is performed in the ambulatory setting using regional anesthesia (RA) to facilitate pain control and same-day discharge1. Patients are discharged when specific criteria are met including pain control. There is a paucity of data on the transition to oral analgesics at home when RA wears off.

Systematic Integration of data from separate data silos such as electronic medical record, and quality assessment/ improvement databases can be used to comprehensively assess the perioperative course.

We aim to report specific outcomes on post operative day (POD) 1, pain intensity and functional recovery, following single shot RA for analgesia after orthopedic ambulatory surgery using an integrated database customized for RA outcomes.

Methods: An IRB approved integrated outcomes database was created using the Institution EMR, Anesthesia Information Management System (AIMS) and RA specific database. A Java-Spring web-application was developed on top of an Oracle database to transform, validate, and consolidate data from different hospital database environments (Oracle, SQL Server, and Netezza). The web application provides an interface for manual cleaning of unreliable records and data entry for study specific data sources. This database was used to retrospectively review patients who underwent pediatric orthopedic procedures with RA from Dec. 2014 to Jan. 2016. Patients were categorized as < 15 years old and >15 years to accommodate outcomes surveys designed for specific age groups. POD 1 follow-up phone calls included a validated single question survey of functional recovery asking to estimate “POD 1 percentage of baseline function”3. PACU maximum and POD1 pain scores were categorized as low (0-<4), medium (> 4- <7) and high (> 7).

Results: 295 patients were enrolled in the database during the study period. The block success rate was 97% for patients <15yo and 99 % for patients > 15yo. Mean ages in younger and older groups (SD) were 12.7 (2.2) and 19.3 (4). Six surgical categories (anterior cruciate ligament repair, other knee ligament repair, open shoulder, shoulder arthroscopy, open foot and ankle surgery, hip arthroscopy) were treated with a combination of 7 RA single shot blocks. PACU pain levels vs. pain and recovery levels on POD 1 are shown in Table 1.

Discussion: In spite of RA, high percentages of patients (younger more than older) report unmanageable pain on POD1 with calls to the surgeon. In patients > 15, high maximum pain category in PACU was associated with high POD 1 pain scores, reported unmanageable pain and delayed functional recovery. In patients < 15years, POD1 pain scores, reports of unmanageable pain and functional recovery were independent of PACU pain category. It is unclear why patients < 15 report no severe POD 1 pain but report a high incidence of unmanageable pain. Both groups show delayed return to baseline function associated with high PACU pain category.

Conclusion: Patients having major orthopedic surgery on an outpatient basis have significant pain and delayed return to baseline function in the home environment. Knowledge of prevalence of post-discharge pain and delayed recovery may guide practice models.

References:

1 Williams B, Vogt M, et al. Economics of nerve block pain management after anterior cruciate ligament reconstruction: hospital cost savings via associated postanesthesia care unit bypass and same-day discharge. Anesthesiology 2004;100(3):697

2 Kluivers K, Riphagen I, et al. Systematic review on recovery specific quality of life instruments. Surgery 2007;143(2): 206
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