Pediatric Anesthesia ISSN 1155-5645
ORIGINAL ARTICLE
Preoperative preparation workshop reduces postoperative maladaptive behavior in children € rlin1,2, Joelle Kinderf1, Cecile Ghez1, Sabrina Menrath2,3, Julie Hilly1,2, Anne-Laure Ho 4,5 Honorine Delivet , Christopher Brasher1, Yves Nivoche1,2 & Souhayl Dahmani1,2,6 1 2 3 4 5 6
University Hospital, Paris Diderot University, Paris, France Department of Anesthesia, Intensive care, Robert Debre Denis Diderot University, Paris, France University Hospital, Paris Diderot University, Paris, France Department of Peadiatric Orthopedics, RobertDebre University Hospital, Paris Diderot University, Paris, France Department of Pain Management, Robert Debre Descarte University, Paris, France Rene University Hospital, Paris, France DHU PROTECT INSERM U 1141, Robert Debre
What is already known
• Preoperative family-centered behavioral preparation has been shown to reduce preoperative anxiety, opioid consumption, and PACU length of stay.
What this article adds
• The introduction of a preoperative family workshop in our institution resulted in a reduction in postoperative maladaptive behaviors (3.6% vs 35.7% in case vs control groups).
Implications for translation
• This result suggests the usefulness of preoperative preparation programs in pediatric surgery.
Keywords postoperative; pediatric; emergence agitation; pain; postoperative maladaptive behaviors Correspondence Dr. Julie Hilly, Department of Anesthesia Hospital, and Intensive Care, Robert Debre rurier, 75019 Paris, France 48 Bd Se Email:
[email protected] Section Editor: Adrian Bosenberg Accepted 30 April 2015 doi:10.1111/pan.12701
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Summary Introduction: Postoperative maladaptive behaviors (POMBs) are common following pediatric anesthesia, and preoperative anxiety is associated with POMBs. A family-centered preoperative preparation workshop was instituted with the aim of reducing the incidence of POMB and preoperative anxiety, and the study was constructed to evaluate its effectiveness. Material and methods: A prospective cohort study was constructed, comparing patients who attended the workshop (workshop group) with patients who did not attend and who were matched for age and type of surgery (comparison group). Preoperative anxiety was measured using the mYPAS score, postoperative emergence agitation (EA) was measured using the PAED score, POMBs were assessed with the Post-Hospital Behavior Questionnaire (PHBQ) on postoperative day 7, and PACU morphine consumption and PACU length of stay were recorded. Statistical analysis was performed employing the X² test, the Fisher’s exact test, and the Mann– Whitney test as appropriate. Data were expressed as median [minimum, maximum]. Results: Fifty-six patients from 3 to 18 years of age were recruited. Twentyseven patients in the workshop group were compared to 26 in the comparison group, after exclusions for missing data. Significant differences were demonstrated between groups for POMBs intensity (PHBQ score 2 [0; 9] vs 5 [0; 10], P = 0.008) and incidence (PHBQ score >6: 3.6% vs 35.7%, P = 0.003), and © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 990–998
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for mYPAS score (28 [23; 87] vs 37 [23;100], P = 0.015). No difference was found for EA, PACU morphine consumption, or PACU length of stay. Conclusion: The workshop appears to result in reduced preoperative anxiety and POMBs.
Introduction Over the last decade, numerous studies have examined the occurrence of postoperative neuro-cognitive complications in children (1), notably emergence delirium, also known as emergence agitation (EA), and postoperative maladaptive behaviors (POMBs). POMBs are measured after discharge from hospital, and occur particularly after ambulatory surgery. It involves nightmares, sleep disturbances, bed wetting, temper tantrums, attention seeking, and the fear of being alone. Previous works have demonstrated a strong relationship between preoperative anxiety and both postoperative emergence delirium and maladaptive behavior (2–6). As such, interventions that reduce preoperative anxiety may lead to reduced incidences of POMBs. Recent works demonstrate a significant preventive effect of preoperative family-centered preparation upon preoperative anxiety, emergence agitation, and postoperative pain (3). However, whether such preparation reduces the occurrence of the postoperative maladaptive behaviors has not been examined. A preoperative patient preparation workshop was developed in our institution, based upon the model developed by Kain and collaborators (3). The main aim of our study was to compare the incidence of the postoperative maladaptive behavior in patients prepared by the workshop to matched patients without preparation. Material and methods This study is a prospective observational matchedcohort study performed from January 2013 to February 2014. It was approved by our institutional IRB (Comite d’Evaluation de l’Ethique des projets de Recherche Biomedicale (CEERB) Paris Nord; #2013/97). Informed written consent was obtained from all the parents (in the workshop and the comparison groups), and assent or consent obtained from patients where age-appropriate. For pictures displayed in the manuscript, all patients and parents gave their oral and written consent for publication. Inclusion and exclusion criteria Inclusion criteria were patients aged more than 3 years and strictly younger than 19 years of age and ASA © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 990–998
status 1 or 2. Exclusion criteria were patients aged 46 (7), patient anxiety as a mYPAS >24 (8), emergence delirium as a PAED scale >9 (9), and postoperative maladaptive behavior as a PHBQ >6 (2,5,6,11). All measurements and questionnaires were delivered by caregivers blind to case–control status. The 15-min timing for emergence agitation assessment was based on previous studies showing postoperative emergence delirium to occur during a mean PACU stay of 14 min (1,10). The 7-day timing for maladaptive behavior assessment was chosen as 90% of patients are discharged by day 6 in our institution, and secondly because maladaptive behavior decreases over time (2), rendering delayed assessment less effective. Finally, the potential impairment of postoperative rehabilitation by an early occurrence of postoperative maladaptive behaviors makes the prevention of this complication during this crucial period more relevant. The PHBQ lists 26 items (general anxiety withdrawal, eating disturbances, separation anxiety, regression– aggression, sleep anxiety and one item in relation with sibling excluded) (2,12,13). Parents were asked to rate each item as negatively modified, positively modified, or unmodified, as originally described by Vernon et al. (12). When an item was not evaluable because of surgery (e.g. eating disturbances with ENT surgery) or patients characteristics (age), this item was considered © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 990–998
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unchanged. As per previous publications, if data were missing for 21 or more items, then patients were excluded from analysis. The sum of negatively modified items gave a score which was considered postoperative maladaptive behavior when >6 (2,13). The cut-off value for PHBQ was set to 6 according to the study of Stargatt and collaborators (2) showing that most patients exhibited 6) at postoperative day 7. To achieve this, the workshop intervention group was compared to matched comparison group. Given the previously published incidence of postoperative maladaptive behavior (24%) using the same criteria of PHBQ >6 (2) and an expected reduction in the incidence of this complication >5%, 28 patients were required to achieve a statistical difference with a study power of 80% and an alpha risk of 5%. There were no previous studies to guide estimations of the decrease in postoperative maladaptive behaviors incidence following preparatory workshop intervention. A reduction of 5% was predicted conservatively. Sample size estimation was performed using the Lyon Statistics University online calculator (http://www.spc.univ-lyon1.fr/mfcalc/). Continuous data were expressed as median [minimum, maximum]. Comparisons of these data were performed using the Mann and Whitney tests and were expressed as mean difference [95% confidence interval]. For discrete variables, data were expressed as N (%). The v2 or exact test of Fisher was used for their comparison and outcomes were expressed as odds ratio [95% confidence interval]. As stated earlier, if data were missing for 21 or more PHBQ item differences, patients were excluded from analyses. Statistical analyses were performed using the SPSS 20.0 software (IBM Company, Chicago, IL, USA). The level of significance was set as 5%. Results During the study period, 1050 patients were proposed to participate in the workshop and 28 agreed to participate in the workshop and the study. All patients proposed to participate in the comparison group agreed. The final study cohort included 56 patients (28 in each arm). One patient in the workshop group and two in the comparison group were excluded because of incomplete data collection, and analyses were performed on 53 patients. All patients in the comparison group were 993
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[0.01; 0.53], P = 0.003, respectively). Detailed differences in PHBQ scores and individual PHBQ items are summarized in Figure 3 and Table 4, respectively. Significantly less negative behaviors were observed for separation anxiety troubles and regression–aggression (Table 4).
consecutive and followed the same order of recruitment that those in the workshop group. Demographic, surgical, and anesthesia data are displayed in Table 1. PACU length of stay and morphine consumption did not differ significantly (Table 2), nor did PAED scores or parental STAI-A scores (Table 3). The mYPAS scores were decreased in the workshop group (Table 3: 23 [23; 87] vs 37 [23; 100], P = 0.01). The PHBQ scores were also significantly decreased in the workshop group (Table 3: 2 [0; 9] vs 5 [0; 10], P = 0.008). While mYPAS scores >24 were equally distributed between the two groups, PHBQ scores >6 defining POMBs were found significantly less frequently in the intervention group in comparison to controls (Table 3; 3.6% vs 35.7%, odds ratio = 0.06
Discussion The most important finding of the current study is that the preoperative preparation workshop attendance was associated with a significant reduction in the postoperative maladaptive behavior, measured as the absolute value of PHBQ (2 [0; 9] vs 5 [0; 10], P = 0.008) and a
Table 1 Patient, anesthesia, and surgical characteristics
Age (years) Weight (kg) Gender (Male) Premedication Preschool children Parental presence during the workshop Duration of anesthesia (min) Duration of surgery (min) Regional anesthesia Inhaled anesthesia induction Intraoperative analgesics Surgeries
Workshop group
Control group
7 [3; 16] 23 [10; 60] 12 (43%) 9 (32%) 11 (39%) 26 (93%)
5.5 [3; 16] 22.5 [12; 62] 12 (43%) 8 (29%) 13 (46%) –
75 [10; 500] 40 [8; 270] 9 (32%) 21 (75%) 27 (100%) Adenotonsillectomy (N = 8) Spinal arthrodesis (N = 2) Laparoscopic vesico-ureteral reflux surgery (N = 3) Femoral osteotomy (N = 2) Thoracoplasty (Nuss) (N = 1) Cutaneous tumorectomy (N = 1) Tonsillectomy (N = 1) Adenoidectomy (N = 1) Dental surgery (N = 1) Transtympanic drains (N = 1) Otoplasty (N = 2) Circumcision (N = 1) Laparoscopic cholecystectomy (N = 1) Splenectomy (N = 1) Colonoscopy (N = 1)
85 [10; 375] 47.5 [5; 240] 8 (29%) 17 (61%) 26 (96%) Adenotonsillectomy (N = 8) Spinal arthrodesis (N = 2) Laparoscopic vesico-ureteral reflux surgery (N = 3) Femoral osteotomy (N = 2) Thoracoplasty (Nuss) (N = 1) Cutaneous tumorectomy (N = 1) Tonsillectomy (N = 1) Adenoidectomy (N = 1) Dental surgery (N = 2) Transtympanic drains (N = 1) Otoplasty (N = 1) Circumcision (N = 1) Laparoscopic cholecystectomy (N = 1) Splenectomy (N = 1) Colonoscopy (N = 0)
Data are expressed as median [minimum; maximum] or N (percentage).
Table 2 Postoperative care unit patient characteristics
PACU length of stay (min) Morphine titration in PACU PACU morphine consumption (mgkg 1)
Workshop group
Control group
120 [75; 1170] 5 (18%) 0 [0; 0.22]
110 [30; 1440] 4 (14%) 0 [0; 0.18]
Mean difference (MD) or odds ratio (OR) MD = 33 [ 103; 170] OR = 1.25 [0.3; 5.28] MD = 0.002 [ 0.002; 0.003]
P 0.06 0.5 0.79
Data are expressed as median [minimum; maximum], N (percentage), mean difference [95% confidence interval], or odds ratio (OR) [95% confidence interval].
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Table 3 Study outcomes
mYPAS mYPAS >24 STAI STAI >46 PAED PAED >9 PHBQ PHBQ >6
Workshop group
Control group
Mean difference (MD) or odds ratio (OR)
P
23 [23; 87] 17 (61%) 39 [23; 58] 9 (32%) 10 [0; 20] 11 (41%) 2 [0; 9] 1 (3.6%)
37 [23; 100] 23 (82%) 39 [20; 62] 12 (43%) 8 [0; 20] 11 (42%) 5 [0; 10] 10 (35.7%)
MD OR MD OR MD OR MD OR
0.01 0.07 0.5 0.29 0.67 0.57 0.008 0.003
= = = = = = = =
10 [ 20; 0] 0.22 [0.04; 1.02] 0.4 [ 7; 6] 0.6 [0.2; 1.77] 1.7 [ 2.5; 4.2] 0.94 [0.31; 2.80] 2 [ 3.3; 0.6] 0.06 [0.01; 0.53]
Significant comparisons are displayed in bold. PAED, Pediatric Anesthesia Emergence Delirium scale; PHBQ, Post-Hospital Behavior Questionnaire. Data are expressed as median [minimum; maximum] or N (percentage), mean difference [95% confidence interval], or odds ratio (OR) [95% confidence interval].
(a)
(b)
Figure 3 Post-Hospital Behavior Questionnaire (PHBQ) score frequency distribution (sum of negative items) in control (a) and workshop (b) groups.
PHBQ score >6 (3.6% vs 35.7%, odds ratio = 0.06 [0.01; 0.53], P = 0.003) on postoperative day 7. Items improved in the PHBQ were in relation with separation © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 990–998
anxiety troubles and regression–aggression (fear from doctors and hospital, temper tantrums, and difficulties in doing thing such as playing games). Patient preoperative anxiety was also decreased (23 [23; 87] vs 37 [23; 100], P = 0.01). Since its first description in 1945 by Levy, numerous studies have focused on the incidence and characteristics of postoperative maladaptive behavior. Vernon and collaborators (10) subsequently developed a PHBQ allowing for diagnosis standardization. Further studies have investigated the incidence and risk factors associated with the occurrence of POMB, and the reported incidence ranges from 28% to 88% (5). Kotiniemi and collaborators found an incidence of 49% at day 1 and 9% at day 30 (14). However, these authors defined POMBs as the presence of at least one negative change on the PHBQ score. Using the same definition of PHBQ than used in our study (more than six negative items on the PHBQ), Stargatt et al. (2) found an incidence of 24% at day 3 and 16% at day 30. The incidence of the POMB in our study (35.7% found in the control group at postoperative day 7) is consistent with previously reported values (e.g., 24% at day 3, Stargatt et al. (2)). The overall decrease in postoperative maladaptive behavior observed for workshop attendees might involve a reduction in preoperative anxiety. Patients and parents were reassured by participation in the workshop, preventing some anxiety, and reducing POMB as a result. This hypothesis is supported by the observed decrease in postoperative anxiety in the workshop group when compared to patients in the comparison group. Preoperative anxiety is associated with both emergence agitation and POMB (1,4). However, our study did not describe a reduction in the incidence of emergence agitation in the intervention group. This result might be due to a lack of statistical power as it was constructed to demonstrate differences in POMB. In 995
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Table 4 Frequency of negative Post-Hospital Behavior Questionnaire (PHBQ) items in control and workshop groups PHBQ items
Control N (%)
Workshop N (%)
P
1. Does your child need a pacifier 2. Does your child seem to be afraid of leaving the house with you 3. Is your child uninterested in what goes on around him ⁄ her 4. Does your child bite his/her finger nails 5. Does your child seem to avoid or be afraid of new things 6. Does your child have difficulty making up his/her mind 7. Is your child irregular in his/her bowel movements 8. Does your child suck his/her fingers or thumb 9. Does your child get upset when you leave him/her alone for a few minutes 10. Does your child seem to get upset when someone mentions doctors or hospitals 11. Does your child follow you everywhere around the house 12. Does your child spend time trying to get or hold your attention 13. Does your child have bad dreams at night or wake up and cry 14. Does your child make a fuss about going to bed at night 15. Is your child afraid of the dark 16. Does your child have trouble getting to sleep at night 17. Does your child make a fuss about eating 18. Does your child spend time just sitting or lying and doing nothing 19. Does your child have a poor appetite 20. Does your child have temper tantrums 21. Does your child break toys or other objects 22. Does your child tend to disobey you 23. Does your child wet the bed at night 24. Does your child need a lot of help doing things 25. Is it difficult to get your child interested in doing things (playing games, with toys, etc.) 26. Is it difficult to get your child to talk to you 27. Does your child seem to be shy or afraid around strangers
0 (0) 2 (7) 4 (11) 3 (11) 7 (25) 5 (18) 1 (4) 1 (4) 8 (29) 7 (25) 4 (14) 8 (29) 3 (11) 4 (14) 0 (0) 4 (14) 12 (43) 2 (7) 12 (43) 7 (25) 0 (0) 7 (25) 2 (7) 6 (21) 9 (32) 2 (7) 1 (4)
0 (0) 0 (0) 3 (11) 2 (7) 3 (11) 7 (25) 2 (7) 2 (7) 3 (11) 1 (4) 2 (7) 2 (7) 3 (11) 2 (7) 3 (11) 5 (18) 6 (21) 2 (7) 9 (32) 1 (4) 0 (0) 2 (7) 1 (4) 3 (11) 2 (7) 3 (11) 0 (0)
– 0.24 0.5 0.5 0.13 0.4 0.5 0.5 0.08 0.02 0.03 0.03 0.65 0.32 0.12 0.52 0.06 0.7 0.25 0.02 – 0.06 0.5 0.21 0.02 0.5 0.5
addition, emergence agitation was evaluated 15 min after admission to the PACU, while this complication has been described to occur up to 45 min after the admission to the PACU (10). Incidence of emergence agitation in our sample averaged 40%, high in comparison to 20% in one recently published study (1). This may be due to the absence of pharmacological preventive measures such as alpha-2 agonists, propofol-based anesthesia, and perioperative ketamine (15). Morphine consumption and PACU length of stay were also unaffected by preoperative preparation, which may once again be due to the lack of statistical power. Our study has limitations. Firstly, the absence of randomization and the double selection process for each study group might have introduced a selection bias. Patients in the workshop group were volunteers. Consequently, they might have been more sensible to the effect of the workshop because of their internal behaviors (such as anxiety trait), because of the surgery performed (scoliosis surgery and invasive procedures with more important postoperative pain), or because of their belief in the efficacy of the workshop. This might explain the high incidence of preoperative anxiety and emergence agitation observed in our study. The selection of the 996
comparison group was also a limitation of the study: patients were selected to meet the matched criteria rather on their consecutive date of intervention. However, given the few number of patients included in the study, the time between patients in the workshop group allowed to recruit patients of the comparison group in a consecutive manner. Secondly, the POMBs assessment was performed at postoperative day 7 and as such, results of the current study could not be extrapolated to longer postoperative periods. Incidence of this complication has been previously found to decrease over time (2). Consequently, our study cannot answer to the question of the benefice of our workshop after the seventh postoperative day and the consequences of this reduction in POMBs incidence on the postoperative rehabilitation of patients. Given the previous studies that found the transient nature of POMBs (the incidence of POMB has been found to decrease to 16% at day 30 (2)), one can question the benefits of preventing this complication considering the cost of establishing a workshops using many caregivers resources (six specialized paramedical caregivers and one psychologist). Investigating the efficacy of the same workshop with a reduced number of caregivers would be helpful in determining the optimal © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 990–998
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resources to be used in such a workshop. Thirdly, anesthesia and analgesia protocols were standardized but one cannot exclude that a difference could occur in these protocols between the two groups. Lastly, the PHBQ tool used in this study has been frequently criticized for its accuracy and methods of interpretation. The PHBQ is on old and poorly validated tool used for research and there is no clear agreement on how it should be used in the clinical practice. It was initially validated in a small cohort of patients undergoing adenotonsillectomy (12) and it appears to be more accurate in younger children (6 for defining POMBs used in our study has been used by only two studies (2,13) making comparisons with other studies difficult. Finally, no clear interpretation can be made based on behaviors area modified either when they show a deterioration or improvement, making this questionnaire nonuseful for detecting changes in a particular behavior area (6).
In conclusion, our study found that preoperative preparation in a workshop format employing scale models and figurines, and explanation about the perioperative experience significantly decreased the incidence of the postoperative maladaptive behaviors on postoperative day 7. Our finding, which suggests that a preoperative preparatory workshop can decrease POMBs, would best be confirmed in a prospective randomized controlled trial. Funding This study was funded by institutional resources. Conflict of interest Financial disclosure: None. The authors report no conflict of interest.
References 1 Dahmani S, Delivet H, Hilly J. Emergence delirium in children: an update. Curr Opin Anaesthesiol 2014; 27: 309–315. 2 Stargatt R, Davidson AJ, Huang GH et al. A cohort study of the incidence and risk factors for negative behavior changes in children after general anesthesia. Pediatr Anesth 2006; 16: 846–859. 3 Kain ZN, Caldwell-Andrews AA, Mayes LC et al. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007; 106: 65– 74. 4 Kain ZN, Mayes LC, Caldwell-Andrews AA et al. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 2006; 118: 651–658. 5 Cohen-Salmon D. Perioperative psychobehavioural changes in children. Ann Fr Anesth Reanim 2010; 29: 289–300.
6 Davidson A, Howard K, Browne W et al. (2012) Preoperative Evaluation and Preparation, Anxiety, Awareness, and Behavior Change, in Gregory’s Pediatric Anesthesia. In Gregory GA, Andropoulos DB, eds. Oxford, UK: Fifth Edition Wiley-Blackwell. 7 Heiney SP, Bryant LH, Walker S et al. Impact of parental anxiety on child emotional adjustment when a parent has cancer. Oncol Nurs Forum 1997; 24: 655–661. 8 Kain ZN, Mayes LC, Cicchetti DV et al. The Yale Preoperative Anxiety Scale: how does it compare with a “gold standard”? Anesth Analg 1997; 85: 783–788. 9 Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 2004; 100: 1138–1145. 10 Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit. Anest Analg 2003; 96: 1625–1630.
11 Kain ZN, Mayes LC, O’Connor TZ et al. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med 1996; 150: 1238–1245. 12 Vernon DT, Schulman JL, Foley JM. Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates. Am J Dis Child 1966; 111: 581–593. 13 Faulk DJ, Twite MD, Zuk J et al. Hypnotic depth and the incidence of emergence agitation and negative postoperative behavioral changes. Pediatr Anesth 2010; 20: 72–81. 14 Kotiniemi LH, Ryh€ anen PT, Moilanen IK. Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia 1997; 52: 970–976. 15 Dahmani S, Stany I, Brasher C et al. Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010; 104: 216–223.
Appendix 1 Postoperative intravenous morphine administration
S, sedation scale with S0: awake; S1, intermittently asleep but easily woken; S2, asleep but woken by verbal stimulation; S3, asleep and woken by tactile stimulation. 1 Intravenous morphine titration i Initial bolus: 100 lgkg 200 lgkg 1) © 2015 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 990–998
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ii Subsequent doses: 25 lgkg 1 every 5–7 min to effect (VAS ≤ 30 mm; mild pain; EDIN ≤ 5, DAN ≤ 3, OPS < 3, Facial pain scale < 3)1 iii S2 sedation = stop titration
(Usual total dose: 100– 1
VAS, the DAN scale, the EDIN scale, the OPS and the FPS. 997
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2 PCA protocols i Bolus only: moderate pain Bolus: 15–25 lgkg 1 Refractory Period: 5–10 min Maximum dose per 4 h: 400 lgkg 1 ii Background infusion + Bolus: intense pain Background infusion 10–30 lgkg 1h 1 Bolus: 20 lgkg 1 Refractory Period: 5–10 min Maximum dose per 4 h: 400 lgkg 1 To be used particularly at night and during the first 24–48 h postoperatively
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4 Additional prescriptions Laxatives prescribed immediately upon re-feeding Pruritus: Nalbuphine 0.12 mgkg 1day 1 (10% analgesic dose) PONV prevention and treatment as per protocols 5 Multimodal analgesia unless contraindicatedParacetamol, NSAIDs, Nefopam (for age >16 years) 6 Consider background infusions and bolus PCA for all spinal surgery and cerebral palsy patients 7 No background infusions and increased attention to patients with renal impairment
3 Monitoring sedation scale dependent S0 = every 4 h S1 = hourly
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