<p><strong>BACKGROUND: </strong>Postoperative nausea vomiting (PONV) after elective outpatient surgery can complicate discharge and increase patient suffering. Within our hospital system, there was variability in the use of PONV prophylaxis for patients undergoing anterior cruciate ligament (ACL) reconstruction, which resulted in variable outcomes. To address this variability, we designed and implemented a standardized PONV prophylaxis guideline for the care of this surgical population.</p>

<p><strong>AIM: </strong>We sought to develop and implement a standardized PONV prophylaxis guideline for all patients presenting for elective ambulatory ACL reconstruction with the goal of reducing the rate of emesis to less than or equal to 5%.</p>

<p><strong>METHODS: </strong>We convened a multidisciplinary team to develop a PONV prophylaxis guideline which included administration of dexamethasone, ondansetron, and a low-dose propofol infusion in addition to a femoral and sciatic nerve block and routine ketorolac administration for pain control. Our primary outcome, emesis rate, was tracked using a P-chart. Process measures included use of guideline medications and balancing measures included opioid administration, pain scores, and emergence time.</p>

<p><strong>RESULTS: </strong>We analyzed PONV outcomes for 817 patients from January 1, 2014, to December 31, 2018. The baseline postoperative emesis rate for all anesthetizing locations was 17%. Following, guideline implementation, the emesis rate decreased to 5%. Opioid administration was decreased following guideline implementation. The percentage of patients managed without any perioperative opioids increased from 16% in the baseline group to 38% following guideline implementation. The P-chart suggests that the observed reduction in emesis rate represents special cause variation and this reduction was sustained over a two-year period.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of standard PONV guidelines for adolescents undergoing outpatient ACL reconstruction was associated with lower emesis rates. This reduction in emesis rate may have been due to the concurrent reduction in opioids we observed following guideline implementation.</p>

<p><strong>BACKGROUND: </strong>Cure rates for acute lymphoblastic leukemia (ALL) have improved, but as therapy has intensified, the burden of osteonecrosis (ON) has increased. Limited data exist regarding surgical interventions for pediatric ALL patients with ON.</p>

<p><strong>MATERIALS AND METHODS: </strong>A multi-center cohort of children with newly diagnosed ALL was established with Pediatric Health Information System (PHIS) data from 43 freestanding children's hospitals from 1999 to 2011. Patients with ON identified by International Classification of Diseases, Ninth Revision (ICD-9) code were followed for up to 5 years after index ALL admission for the presence of ON-associated orthopedic surgical procedures.</p>

<p><strong>RESULTS: </strong>A cohort of 10,729 ALL patients was assembled, of which 242 (2.33%) were identified with an ICD-9 code for ON within 5 years of ALL diagnosis. Fifty-five patients (22.7%) with ON underwent orthopedic surgical intervention aimed at joint preservation (82%) or replacement (18%) with substantial practice variation by hospital in both the rate and type of surgical intervention. The majority of patients had surgical procedures while receiving maintenance therapy. None of the patients undergoing surgical intervention required intensive care unit-level care within 14 days of surgery, and there was no associated in-hospital mortality.</p>

<p><strong>CONCLUSIONS: </strong>No standard of care exists for treatment of ALL-associated ON. While considerable practice variation exists, surgical intervention appears relatively safe.</p>