Postoperative orthopaedic neurovascular monitoring in the pediatric population

BACKGROUND: Many orthopaedic procedures carry risks of neurovascular compromise. We hypothesized that risk factors for neurovascular compromise and for its delayed detection exist in the pediatric orthopaedic population. METHODS: We searched our institution's pediatric patient database from January 2004 through December 2006, randomly selecting (arbitrarily choosing every 20th patient) 286 patients, 34 of whom went to the operating room twice for 320 procedures. We retrospectively reviewed their records for these potential risk factors: altered communication ability (for age), abnormal baseline neurovascular status, imprecise documentation of neurovascular baseline status, nonspecific or inappropriate postoperative monitoring orders, and monitoring not carried out by nursing staff. Outcomes were analyzed via Fisher exact test (P < 0.05). RESULTS: Ten patients (3%) had new postoperative neurovascular events, and 4 (1%) were recognized to have neurological deterioration detected on a delayed basis. Fifty-seven (18%) had impaired communication ability (significant correlation with increased risk for neurovascular events), 97 (30%) had abnormal neurovascular preoperative status, and 21 (22%) had no specific documentation of neurovascular condition in the perioperative chart. Insufficient documentation of abnormal neurovascular baseline correlated significantly with an increased risk for delayed detection of postoperative neurovascular events. Although all written orders for neurovascular checks were carried out and specific with respect to timing, 133 patients (42%) had neurovascular monitoring orders that were nonspecific about the functions to be checked. All patients with delayed deficit detection had impaired ability to communicate, abnormal baseline values, or improperly written orders. CONCLUSIONS: The risk of postoperative neurovascular events is significantly higher in patients with impaired communication ability, and the risk for delayed detection of such events is significantly higher in patients without proper documentation of an abnormal neurovascular baseline. Clear documentation of baseline function may avoid delayed detection, and more specific monitoring processes may improve patient safety. LEVEL OF EVIDENCE: Retrospective study, level II.