Opioid prescribing patterns following implementation of Enhanced Recovery After Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction

Enhanced recovery after urological reconstructive surgery in pediatric patients: a systematic review and meta-analysis

Enhanced Recovery After Surgery (ERAS) is a protocol that includes rules aimed to minimize surgical stress and to reduce the post-operative period. Initially applied in intestinal surgery of adults, a recent meta-analysis suggested that ERAS is valid also in pediatric gastrointestinal surgery. This study systematically reviewed and performed a meta-analysis to evaluate ERAS benefits in pediatric urological reconstructive surgery. A PubMed search identified studies comparing ERAS and traditional protocols in pediatric urological reconstructive surgery. Data on major and minor complications, hospital readmission, and length of hospital stay were collected and analyzed. Analyses were performed using OR and Cl 95%. A p-value < 0.05 was considered significant. A total of 10 papers met the inclusion criteria, with 1410 included patients (492 ERAS group, 918 No-ERAS). There were significant differences in major complications (p < 0.001) and length of stay (p < 0.001) and the incidence of minor complications (p = 0.002) favoring patients undergoing ERAS protocol; differently, there was no difference in hospital readmission (p = 0.763). ERAS protocol is safe and feasible for children undergoing reconstructive urological surgery, reducing the risks of complications and the length of hospital stay, without increasing readmission risk. ERAS should also be a standardized procedure in pediatric reconstructive urological surgery.

Opioid prescribing patterns and the effect of chronic kidney disease in pediatric urology population: A retrospective cohort analysis

BACKGROUND

Significant efforts have been undertaken to decrease opioid prescribing, but there is little research into patient-specific factors presenting as barriers in the pediatric surgical population. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be a safe and effective alternative to opioids for pain control, however, concerns about their impact on renal function limit their use in patients with chronic kidney disease (CKD). Data is limited on the interplay of CKD on opioid prescribing.

OBJECTIVE

We hypothesized that opioid reduction efforts were successful, but patients with CKD would be more likely to receive an opioid prescription than those without CKD.

STUDY DESIGN

A retrospective cohort study of patients ≤18 years old undergoing urologic surgery from 2014 to 2022 was performed. Patients were stratified by CKD diagnosis, determined by chart diagnosis and confirmed with CKiD U25 eGFR calculations, excluding those with normal eGFR or Stage 1 CKD. Patients without a documented CKD diagnosis and without preoperative renal function testing were presumed not to have CKD. Patients were propensity matched using the optimal full algorithm across 12 different variables. Outcomes of interest were discharge opioid prescriptions, non-opioid analgesic prescriptions, and unscheduled healthcare encounters (urology clinic visits within 5 days, emergency department visits, readmissions, or reoperations within 30 days).

RESULTS

10,604 patients were included. 603 patients (5.7 %) had a pre-existing CKD diagnosis; the majority were CKD stage 2 (77.8 %, 466 patients). A significant decrease in discharge opioid prescriptions was seen for patients with and without CKD. Patients with CKD had greater opioid exposure prior to surgery (17.2 %, 104 versus 2.8 %, 280, p = 0.04). Those with CKD were equally likely to be prescribed NSAIDs (p = 0.36) and opioids (p = 0.09) at discharge. Patients with CKD were more likely to present to the emergency department (ED) within 30 days of surgery (17.6 % versus 7.9 %, p = 0.007).

DISCUSSION

Similar proportions of patients with and without CKD received an opioid prescription at discharge. Patients with CKD were more likely to be exposed to opioids in-hospital earlier than non-CKD counterparts.

CONCLUSIONS

Multiple interventions and a dedicated postoperative opioid reduction protocol worked well, even in patients with CKD where there is concern about safely receiving NSAIDs. All-cause unplanned healthcare encounters did not differ significantly within groups with introduction of these interventions.

Application of the ERAS guidelines in pediatric urological surgery: a systematic review

INTRODUCTION

Consensus for Enhanced Recovery After Surgery (ERAS) in pediatrics has been achieved in neonatal intestinal surgery, yet it is not widely utilized in pediatric urology. We investigated the application of ERAS guidelines in pediatric urology, and determined its effects given the available level of evidence supporting the ERAS protocol in children.

EVIDENCE ACQUISITION

A systematic literature review including series providing adoption of fast-track recovery protocols for pediatric urology procedures was carried out. Main outcome measures were study characteristics, adherence to the 19 ERAS items, complication rates and length of hospital stay. Sub-group analysis by surgery type (hypospadias versus major surgery) was performed.

EVIDENCE SYNTHESIS

Nine series with data from 1272 surgical pediatric cases were included. An enhanced recovery pathway was applied in 67.3% of the reports. Two series included patients undergoing hypospadias repair and ERAS items were insufficiently reported. Studies including children undergoing major procedures mentioned a median of 15 ERAS items, yet applied a median of 11 items. Median compliance rate was 88.9% (range 50-100). More ERAS guideline items were reported (applied or mentioned) in the most recently published studies.

CONCLUSIONS

There is limited reporting and use of the ERAS guidelines in urologic surgery particularly in hypospadias repair; whilst in major surgery in children, adherence and compliance rates vary widely. In more recent series there was an increase in ERAS items that have been mentioned and applied. Future research is needed to identify barriers and to overcome them in order to fully adopt and benefit from the ERAS pathway.

Application of early enteral nutrition nursing based on enhanced recovery after surgery theory in patients with digestive surgery

BACKGROUND

Postoperative nursing can improve the restlessness and gastrointestinal function of patients with tracheal intubation under general anesthesia in digestive surgery. Wide application of various nursing methods and routine nursing in perioperative nursing of patients with general anesthesia in digestive surgery.

AIM

To investigate the impact of early postoperative enteral nutrition nursing based on the enhanced recovery after surgery (ERAS) theory on postoperative agitation and gastrointestinal recovery in patients undergoing general anesthesia that experienced tracheal intubation.

METHODS

The data of 126 patients with digestive surgery from May 2019 to February 2022 were retrospectively analyzed. According to different nursing methods, they were divided into control group and observation group, with 63 cases in observation group and 63 cases in control group. The patients in the control group had standard perioperative nursing care, whereas those in the observation group got enteral nourishment as soon as possible after surgery in accordance with ERAS theory. Both the rate and quality of gastrointestinal function recovery were compared between the two groups after treatment ended. Postoperative anesthesia-related adverse events were tallied, patients' nutritional statuses were monitored, and the Riker sedation and agitation score (SAS) was used to measure the incidence of agitation.

RESULTS

When compared to the control group, the awake duration, spontaneous breathing recovery time, extubation time and postoperative eye-opening time were all considerably shorter (P < 0.05). There was no significant difference in the recovery time of orientation force between the two groups (P > 0.05); however, the observation group had a lower SAS score than the control group (P < 0.05). The recovery time for normal intestinal sounds, the time it took to have the first postoperative exhaust, the time it took to have the first postoperative defecation, and the time it took to have the first postoperative half-fluid feeding were all faster in the observation group than in the control group (P < 0.05); Fasting blood glucose was lower in the observation group compared to the control group (P < 0.05), while the albumin and hemoglobin levels were higher on the first and third postoperative days; however, there was no statistically significant difference in the incidence of anesthesia-related adverse reactions between the two groups (P > 0.05).

CONCLUSION

The extremely early postoperative enteral nutrition nursing based on ERAS theory can reduce the degree of agitation, improve the quality of recovery, promote the recovery of gastrointestinal function, and improve the nutritional status of patients in the recovery period after tracheal intubation under general anesthesia.

Enhanced recovery after surgery in pediatric urology: Current evidence and future practice

PURPOSE

To offer an up-to-date appraisal of the current status of enhanced recovery after surgery (ERAS) protocols in pediatric urology and to provide a guide for the clinical urologist.

MATERIALS AND METHODS

We performed a comprehensive literature search and scoping review on ERAS protocols in pediatric urology using Pubmed (from 1946), Cochrane library, and MEDLINE to December 2021 with the terms ''enhanced recovery'', ''protocolised care'', ''post-operative protocol", ''fast-track surgery'' and ''pediatric urology". Studies were excluded if they did not include perioperative intervention related to urological procedures, no full-text available and in non-English language.

RESULTS

To date, eight clinical studies (involving 1153 patients) have been published on ERAS protocols in pediatric urology. The patients involved ranged from neonates to adolescents, and the urological procedures included bladder augmentation, the Mitrofanoff procedure, laparoscopic pyeloplasty, laparoscopic nephrectomy, hypospadias repair, etc. Multidisciplinary components such as surgical and anesthetic considerations have been employed in ERAS protocols. The length of hospital stay was significantly lower in the ERAS groups with earlier enteral feeding resumption and return of bowel function in pediatric urology patients. The implementation of ERAS protocols does not result in higher complication and readmission rates; instead, some studies have even demonstrated a significant reduction in complication occurrence.

CONCLUSION

ERAS is novel to pediatric urology with a limited scale of published data in the literature. Initial clinical studies revealed that ERAS appears to be efficacious in the field of pediatric urology. Further prospective studies formulating a standardized multimodal protocol are encouraged to better understand key components of ERAS and incorporate ERAS into clinical practice to optimize surgical outcomes for pediatric urology procedures.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis

INTRODUCTION AND OBJECTIVE

Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events.

STUDY DESIGN

All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated.

RESULTS

438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04).

DISCUSSION

The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries.

CONCLUSIONS

Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

Sustained reduction of discharge opioid prescriptions in an enhanced recovery after thoracic surgery program: A multilevel generalized linear model

BACKGROUND

Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery.

METHODS

This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection.

RESULTS

Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (β -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (β -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P < .001; β -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P < .001), intraoperative opioid administration (β -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (β -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (β -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (β -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (β +4.78 morphine equivalent daily dose per year, P = .183).

CONCLUSION

Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration.