In modern medicine there is increasing focus on improving quality of care and patient outcomes. Most of the patients recover from anaesthesia without problems and death relating to anaesthesia is rare nowadays. One of the reasons for the increasing safety of anaesthesia is better monitoring, measures taken intra-operatively to avoid post-operative complications, and better immediate post-anaesthesia care. Early recovery lasts from discontinuation of general anaesthetic until patients have recovered their protective reflexes and motor function. This is the time when complications are most likely to occur and need to be detected and treated.

Perioperative morbidity and mortality could be useful quality indicator. However, a recent review of quality indicators for anaesthesia concluded that conventional perioperative morbidity and mortality data largely lacked the sensitivity and specificity necessary for analysis of variation in quality and safety of anaesthesia. This is because variation in perioperative morbidity and mortality is influenced by a range of patient, surgical, and anaesthetic factors. Variation in the quality of anaesthetic care may be more directly assessed in the immediate postoperative period, in which the patient’s experience of recovery is closely linked to the quality of the anaesthetic and the selection of analgesic and anti-emetic technique. Many of the quality measures are routinely measured by the nursing staff in the recovery room. These parameters include temperature on arrival to the recovery, post operative pain, postoperative nausea and vomiting (PONV) and duration of stay in the recovery.

Postoperative nausea, vomiting (PONV), pain, and hypothermia are commonly encountered in the post-operative recovery room. Various measures are taken intraoperatively to avoid these complications; however, effectiveness of these measures need to be evaluated. Severity of these complications will depend on the surgery performed, intra-operative measures taken and inter-patient differences.

Post-operative nausea and vomiting is extremely unpleasant for the patient also worsen pain control, cause surgical wound disruption, increase risk of aspiration and prevent planned day case discharge. Incidence of PONV in school going children is 34- 50%. It is rare in children below 2 years. In children above 3 years it is >40% and the incidence decreases as child reaches puberty.

Post-operative hypothermia prolongs neuro-muscular blockade, delay awakening, and exacerbates post-operative bleeding. Post-operative shivering cause significant patient discomfort, increases oxygen consumption, CO2 production and sympathetic tone. The incidence of hypothermia depends on the type of surgical procedure. In patients undergoing cardiac surgical procedure the incidence is 30%-60% and in non-cardiac surgical procedures the incidence is 30-50%.

Post-operative pain, especially when poorly controlled, results in harmful acute effects like sympathetic activation, delay return of gastrointestinal function, hyperglycemia, hypercoagulability, decreased respiratory function especially after upper abdominal and thoracic surgery and chronic effects like chronic post-surgical pain, delayed long term recovery. Severe post-operative pain may adversely influence the extent of morbidity and mortality. Studies have shown that the incidence of moderate to severe pain is around 30%- 40%. Our previous audit has shown that the incidence of moderate to severe pain is 10%.

Readmission is an important quality indicator and our audits have shown that 4.8% of the post operative patients are readmitted in 24 hrs.

Aims and Objectives:

1. To know incidence of postoperative nausea and vomiting, hypothermia and worst pain score in post-surgical patients in recovery room.
2. To evaluate the effectiveness of intraoperative measures in reducing post- operative pain, PONV and hypothermia.
3. To study the number of patients requiring readmission in recovery room within 24 hours post operatively.
4. To compare the results of our study with the

This study was carried out after approval from institutional review board. This is a prospective observational study, conducted on the post-operative patients in the post anaesthesia recovery room in Tata Memorial Hospital, Mumbai for a period of two months.

Inclusion Criteria:

All the patients undergoing elective surgical procedure and shifted to postoperative recovery room or ICU.

Exclusion Criteria:

1. Emergency procedures
2. Day care procedures

All the postoperative patients shifted to the recovery room after an elective surgical procedure were assessed for:

1. Post operative
2. Post operative nausea and
3. Temperature on admission to the recovery

Procedure:

Patients’ demographic data and the details of the treatment the patient received in the operation theatre were recorded. We also recorded the details of the anaesthesia technique (GA/GA with epidural/ GA with regional blocks/Regional anaesthesia only) and the type of inhalational agent used intraoperatively (O2 + N2O / O2 + air, Isoflurane / sevoflurane). Duration of anaesthesia was also noted.

Details about intraoperative antiemetics, opioids and other analgesics were also noted. In addition, we recorded the details of intra operative epidural analgesia and the use of Intra operative warming measures like fluid warmer, warming blanket to prevent hypothermia. Any episode of hypotension which required fluid boluses/ mephentermine > 30 mg/ adrenaline or noradrenaline was documented.

Postoperatively if patients were electively ventilated then the reasons for ventilation were recorded.

On admission to the recovery room pain scores were evaluated by NRS (Numeric rating scale) scoring system both at rest and on movement. The severity of pain was classified as follows: 0 – No pain, NRS 1-3 – Mild pain, NRS 4-6 – Moderate pain, NRS 7-10 – Severe pain. Pain scores was also recorded 1 hour after ICU admission and the worst pain score during the ICU stay was documented.

If patient has nausea and vomiting on admission, I hour after admission and within 24 hours of ICU admission it was graded as follows: 0 – No nausea, 1 – mild nausea, 2 – severe nausea, 3 – 1 episode of vomiting, 4 – Two or more episodes of vomiting.

The need for rescue analgesics and anti-emetics on arrival to the recovery room and during their stay in the recovery room was noted.

On admission to the recovery room, patient’s temperature was noted by tympanic membrane temperature probe. Monitoring temperature, pulse, blood pressure and assessment of pain scores in the recovery room is the standard of care.

The number of patients requiring re admission in the recovery room within 24 hours of surgery and the reason for re-admission was noted.

We also recorded the ICU and hospital outcome and the duration of ICU and hospital stay.

Variables Estimated:

Incidence of PONV, worst pain scores and incidence of hypothermia if any in the immediate post operative recovery period.

Number of patients requiring re-admission to recovery room within 24 hours post operatively.

Analysis of the Variables:

Data analyzed as follows:

1. Percentage of patients having nausea on
2. Percentage of patients with episode of vomiting on
3. Percentage of patients with hypothermia on
4. Percentage of patients with worst pain scores on
5. Percentage of patients requiring re-admission within 24 hours of surgery. Univariate/Multivariate logistic regression analysis of the variant affecting the outcome in post-surgical patients was done.

Baseline demographic data

Over a period of 2 months 1,191 elective surgical procedures were carried out and data was collected from 1007 patients.

Hypothermia

With cut-off value of 35°C, 31.4% patients were hypothermic.

According to Pearson Chi square test, we found that there was significant correlation between duration of anaesthesia and hypothermia (p =0.04). However, there was no correlation between hypothermia and use of warming blankets and fluid warmer.

Incidence of hypothermia in surface surgeries i.e. breast, head and neck, bone and soft tissue services was 26.3% (162/617) and in cavity surgeries i.e. gastrointestinal, genitourinary, gynaecology and thoracic surgeries was 39.5% (154/390) and in children <12 years was 35.5% (11/31).

PONV

1.2% of patients had history of PONV. 1.4% had history of motion sickness and 5.9% had history of smoking. 86.3% of patients received antiemetic intraoperatively. 6.6% (66/1007) patients had nausea on ICU admission of which 2.4% (24/1007) had severe nausea.

2% (20/1007) patients had vomiting on ICU admission of which 0.3% (3/1007) had more than 1 episode of vomiting.During ICU stay 2.1% (21/1007) had vomiting of which 0.6% (6/1007) had more than 1 episode of vomiting. 92% of patients with PONV had received antiemetic. There is no correlation between PONV and anti-emetic as the p value is 0.06 according to Pearson Chi square test.

There is no correlation between PONV and history of PONV, smoking, motion sickness, dose of opioids, hypotension, chemotherapy and duration of anaesthesia as the p value was greater than 0.05. There is also no correlation between severe nausea and vomiting with the use of intraoperative antiemetic, duration of anaesthesia and unit.

Female patients were at a higher risk of PONV (p=0.001). Breast patients were at higher risk of PONV (p = 0.001).

Post-operative pain

3.8% of patients had history of pain and received treatment. Epidural drug was used in 22.2% of patients. Epidural was stopped intra-operatively in 13.4% of total patients with epidural in view of hypotension. Epidural band was present in 84.4% of total patients with epidural.

9.8% (99/1007) patients had moderate to severe pain of which 1% (10/1007) had severe pain at rest, and 29.2 % (299/1007) had moderate to severe pain of which 2.2% (22/1007) had severe pain on movement at admission. During ICU stay 2% (20/1007) patients had pain score >7 at rest and 5.8% (58/1007) patients had a pain score>7 on movement.

PCA was attached to7.4% of total patients. However, 33 % of patients with absent epidural band needed PCA and rest were managed with routine analgesics.

Percentage Of Re-Admission Within 24 Hours

1 patient was readmitted to ICU due to bleeding from tracheostomy tube.

Percentage Of Patient Needing Post-Op Ventilation And The Reasons For The Ventilation

3.3% patients required post-operative ventilation. Causes of ventilation, 36.4% patients were in hypothermia, 27.3% had massive blood loss and 45.5% patients had inadequate respiratory attempts. Some patients had more than one reason for postoperative ventilation.

Duration Of ICU Stay And Outcome

All post-operative patients were discharged alive from the ICU during this study period of two months. Patients undergoing breast, bone and soft tissue, gastrointestinal, genitourinary, gynaecology surgery had an average ICU stay of less than 1 day. Patients undergoing head and neck, thoracic, and paediatric surgical procedures stayed for a day, whereas patients undergoing neurosurgical procedures stayed for 2 days in the ICU. 13 patients had an ICU stay for more than 3 days majority of them were from gastrointestinal 30% and thoracic 23% services.

Duration Of Hospital Stay And Outcome

During the study period there was only one hospital mortality. This patient died due to sepsis resulting from an anastomotic leak.

On an average, breast and bone and soft tissue patients stayed for a day, and head and neck, thoracic, gastrointestinal, genitourinary, gynaecology, paediatric and neurosurgery patients stayed for 10 days in hospital. Majority of the patients who had hospital stay of more than 1 month had undergone head and neck surgical procedures.

Correlation Of Hypothermia, PONV, Worst Pain With ICU Stay And Outcome, And With Hospital Stay And Outcome

We could not find any correlation with hypothermia, PONV and worst pain increasing the duration of ICU or hospital stay or affecting the outcome as the p value was >0.05.

The principal findings of our study are as follow:

Over a period of 2 months 1,191 elective surgical procedures were carried out and data was collected from 1007 patients. 51.9% were females and 48.06% were males. 4.3% patients were below 14 years of age.

With the cut off value of 35°C, the incidence of hypothermia at ICU admission was 31.4%. There was a strong correlation between the duration of anaesthesia and postoperative hypothermia (p=0.04).

Patients with hypothermia at ICU admission did not have longer stay in the ICU as compared to those without hypothermia. This was contradicting to the study done by Clara Luís et al where they found that patients with hypothermia stayed longer in PACU. We could not comment on hypothermia affecting the ICU outcome as there was no mortality amongst the patient undergoing elective surgery during this two month period and we have not kept any data on morbidity.

We found that patients undergoing cavity surgery were more likely to develop hypothermia (p =0.001). There was no significant correlation between the incidence of hypothermia in children and adults.

The incidence of hypothermia at ICU admission was higher than in other studies that have considered the same cut-off of 35°C to define hypothermia [1,5,6].

The use of infrared tympanic thermometers to measure the patient’s temperature has been referred as a potential limitation for temperature evaluation. Nierman et al. [7] compared the the “gold standard” of a thermistor in a pulmonary artery catheter to infrared tympanic thermometer. He found that the tympanic thermometer had a bias of 0.1%-0.4% less than the thermistors. Thus, when temperature measurements are made using a tympanic thermometer, it could lead to overestimation of hypothermia [6]. Therefore, considering the greatest reported bias, the real incidence of hypothermia in our study could have been slightly lower. Concerning this subject, Sessler [3] stated that when infrared signals are obtained exactly from the tympanic membrane, the result is real core temperature (Tc). However the size of the device poses certain limitations. If the probe of the tympanic thermometer does not reach the tympanic membrane, then it will not accurately measure the core temperature and will result in overestimation of hypothermia.

Though previous studies have shown that older patients [8-10] had an increased risk for hypothermia, the British National Institute for Health and Clinical Excellence (NICE) [2] assume that age is not an important risk factor for the incidence of hypothermia. In our study, also age is not an independent risk factor for post- operative inadvertent hypothermia.

According to Putzu et al. [4], independently of anaesthesia technique surgical patients always develop peri-operative hypothermia when the surgical procedure lasts more than 30 minutes. In our study, patients with inadvertent hypothermia at ICU admission had longer duration of anaesthesia which differed with the study of Kongsayreepong et al. [1] where they found that the duration of anaesthesia was not considered an independent predictor for hypothermia Forced air warmers are one of the most effective means of warming a patient [13], and there are significant benefits associated with forced-air warming [14]. The extra warming with forced air (compared to routine thermal care) may be effective in reducing the incidence of surgical wound infections [11] and postoperative cardiac complications [12]. In our study, intra-operative temperature monitoring was done in 64.2%, warming blanket was used in 94.1% and fluid warmer in 70.7%. However, the use of warming methods was not an independent protective factor as previously reported [1,15,16]. Though two methods of warming were used in almost 71% of the patients, temperature monitoring was done only in 64.2 % patients. This is because temperature probes are not available in all the operation theatres.

Several studies had demonstrated that infusion of warmed fluids helps in the prevention of hypothermia and reduce the incidence of postoperative shivering [17,18]. We have not found any significant difference with the use of fluid warmer and post-operative hypothermia.

Motamed et al [23], found no significant difference with regards of demographic characteristics, duration, type of surgery, and operative pain medications. They found that the incidence of severe postoperative pain in cancer patients was less than 1% in their institution. Sommer M et al [25], found that the incidence of moderate or severe pain in patients undergoing general surgery was 41% on day 0. Chung F et al [24] in their study found that the incidence of severe pain was 5.3% in the post anaesthesia care unit. Body mass, duration of anaesthesia, and certain types of surgery were significant predictors of pain in the post- anaesthesia care unit. In our study, during the ICU stay, 2% and 5.8% patients had severe pain at rest and on movement respectively. Rescue analgesics were required in 20.8%. However 95.2% of patients who required rescue analgesics had received regular analgesics suggestive of inadequate pain management intraoperatively and postoperatively. There was no significant correlation with intra-operative use of analgesics, duration of anaesthesia and post-operative pain. Pain did not have any effect on duration of ICU and hospital stay. Vanacker BF [20], found that the combination of desflurane with N2O in female patients undergoing breast surgery is associated with a significantly higher incidence of PONV and a higher need of antiemetic drugs, when compared to a N2O free regime.

Fernandez Guisasola J [21], found that the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In subgroup analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60-0.96). When nitrous oxide was used in combination with propofol, the antiemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77-1.15). The authors concluded that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest.

Incidence of hypothermia is same as compared to previous studies. However, the incidence of severe pain is similar to the study done in cancer patients but lower than the patients undergoing general surgical procedures. Rate of re-admission and PONV in a post-surgical patient is very low in our ICU compared to that mentioned in the literature. We need to take further steps in improving the temperature monitoring, to control severe postoperative pain and PONV. Despite of pharmacological advances and known risk factors the incidences of postoperative complications is still higher.

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