In preparing another article for the PAAD, I found myself going down a PONV rabbit hole and found this article by Dr. Meb Watcha and his colleagues at the Texas Children’s Hospital, published in Anesthesia and Analgesia in 2019. Meb first presented this study and the pictorial Baxter Retching Faces (BARF) scale, a validated self-report instrument to quantify nausea, at a SPA poster session about 10 years ago. I always wondered what happened to that study and, low and behold, I simply missed it when it was first published. Hopefully, the PAAD will prevent this from happening in the future. Myron Yaster MD
PS: I believe that Meb retired…If any of you have his present email address, please forward this PAAD to him.
Original article
Mehernoor F Watcha, Andrew D Lee, Eduardo Medellin, M Toni Felberg, Sudha A Bidani. Clinical Use of the Pictorial Baxter Retching Faces Scale for the Measurement of Postoperative Nausea in Children. Anesth Analg. 2019 Jun;128(6):1249-1255. PMID: 31094795
Postoperative nausea and vomiting (PONV) occur more frequently in children than in adults and are one of the most undesirable outcomes of surgery and anesthesia. The almost universal use of prophylaxis with ondansetron, dexamethasone and other anti-emetics has prevented much of this. Or has it? Although vomiting is relatively easy to quantify, nausea not so much so. In today’s PAAD, Watcha et al.1 validated a pictorial scale for measuring nausea, the Baxter Retching Faces (BARF) scale, that they had previously developed2 to quantify nausea in children (figure).
What did they find? The pictorial BARF scale is inexpensive, easy to use and can be used to quantify nausea in children ≥ 6 years of age. It was studied in the PACU but is used in other clinical situations including chemotherapy induced nausea and vomiting3 and could be used in children receiving pain management with opioids. Perhaps most importantly, children in Watcha’s study felt that they should receive antiemetics when their BARF score was > 4 even if this degree of nausea was not accompanied by vomiting. Unlike adults, very young or non-English speaking patients with nausea in the PACU may go untreated until they are vomiting.4
Do you use the BARF scale in your PACUs? Do you send patients home with antiemetics for rescue even if they weren’t vomiting in the PACU and may be nauseous? In outpatient surgery telephone follow ups, are you asking about nausea and vomiting and are you sending patients home with this pictorial scale to use in your assessment? We (GH, MBP) don’t, but wonder if we should. Please send your thoughts and comments to Myron and he will post in a reader response.
References
1. Watcha MF, Lee AD, Medellin E, Felberg MT, Bidani SA. Clinical Use of the Pictorial Baxter Retching Faces Scale for the Measurement of Postoperative Nausea in Children. Anesthesia and analgesia. Jun 2019;128(6):1249-1255. doi:10.1213/ane.0000000000003850
2. Baxter AL, Watcha MF, Baxter WV, Leong T, Wyatt MM. Development and validation of a pictorial nausea rating scale for children. Pediatrics. Jun 2011;127(6):e1542-9. doi:10.1542/peds.2010-1410
3. Donaghey CT, Bowers C, Kiefer J. Evaluation of a nausea assessment tool in the pediatric oncology population. J Spec Pediatr Nurs. Oct 2022;27(4):e12394. doi:10.1111/jspn.12394
4. Gan TJ, Kranke P, Minkowitz HS, et al. Intravenous Amisulpride for the Prevention of Postoperative Nausea and Vomiting: Two Concurrent, Randomized, Double-blind, Placebo-controlled Trials. Anesthesiology. Feb 2017;126(2):268-275. doi:10.1097/aln.0000000000001458