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Herbinger LA. Children and the Opioid Crisis: We Can Make a Difference. J Perianesth Nurs 2024:S1089-9472(24)00049-2. [PMID: 38703178 DOI: 10.1016/j.jopan.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 05/06/2024]
Abstract
The use of opioid-sparing and opioid-free strategies in children can provide adequate analgesia while decreasing the risk of adverse events and contributing to the ongoing battle against the opioid crisis. However, every child must be evaluated individually so that a safe and efficacious perioperative pain management plan can be created. A working knowledge of the risks and benefits of opioids, nonopioid adjuncts, and regional anesthesia along with the ethical considerations for balancing stewardship and beneficent care is essential to the success of these strategies. As perioperative practitioners caring for children, we have an obligation to consider opioid-sparing and opioid-free strategies to promote overall best outcomes. We can make a difference, one child at a time.
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Affiliation(s)
- Lisa Allison Herbinger
- Department of Nurse Anesthesia, Samford University, Birmingham, AL; Department of Anesthesia, Children's of Alabama, Birmingham, AL.
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Bašković M, Markanović M, Ivanović S, Boričević Z, Alavuk Kundović S, Pogorelić Z. Risk Factors Leading to Overnight Stays in Pediatric Surgical Outpatients. CHILDREN (BASEL, SWITZERLAND) 2024; 11:382. [PMID: 38671599 PMCID: PMC11049595 DOI: 10.3390/children11040382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Same-day surgery implies patient discharge on the same day after the surgery. The main aim of the research was to determine which predisposing factors lead to children treated with same-day surgery not being able to be discharged on the same day. METHODS For the purposes of this research, the electronic records of patients in the hospital information system were reviewed retrospectively. The search included patients who were surgically treated through the Day Surgery Unit at the Children's Hospital Zagreb with various diagnoses from 1 January 2021 to 31 December 2023. The target group consisted of patients who could not be discharged on the same day (n = 68), while for the purposes of the control group (n = 68), patients were randomly selected, comparable by age and gender, who were discharged from the hospital on the same day in accordance with the principles of same-day surgery. RESULTS In relation to the parameters of interest between the groups, statistically significant differences were observed in the type of general anesthesia (p = 0.027), the use of analgesics (p = 0.016), the time of entering the operating room (p = 0.000), the time of leaving the operating room (p < 0.0001) and the duration of surgery (76.81 ± 37.21 min vs. 46.51 ± 22.46 min, p < 0.0001). When explanatory variables were included in the regression model, they explained 38% of the variability in the dependent variable. Only the variable "duration of surgery" provided significant information to explain the variability in the dependent variable (p = 0.004). CONCLUSIONS Although the duration of surgery was imposed as the main predictor of hospitalization after same-day surgery, and considering the extremely small number of studies on the mentioned topic, especially in the pediatric population, further, preferably multicenter research on the mentioned topic is needed.
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Affiliation(s)
- Marko Bašković
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia; (M.B.)
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Martina Markanović
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia; (M.B.)
- Day Surgery Unit, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
| | - Sanja Ivanović
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia; (M.B.)
- Day Surgery Unit, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
| | - Zrinka Boričević
- Department of Surgery, General Hospital Karlovac, Ulica Andrije Štampara 3, 47000 Karlovac, Croatia
| | - Sandra Alavuk Kundović
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- Department of Anesthesiology, Reanimatology and Intensive Care Medicine, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
| | - Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Spinčićeva Ulica 1, 21000 Split, Croatia
- Department of Surgery, School of Medicine, University of Split, Šoltanska Ulica 2a, 21000 Split, Croatia
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Nair AA, Placencia JL, Farber HJ, Aparasu RR, Johnson M, Chen H. Trends in Repeat Opioid Analgesic Prescription Utilization for Acute Pain in Children: 2013-2018. Acad Pediatr 2023:S1876-2859(23)00372-8. [PMID: 37802247 DOI: 10.1016/j.acap.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE Our study examined the change in repeat opioid analgesic prescription trends in children and adolescents experiencing acute pain between 2013 and 2018. METHODS Eligible individuals were children and adolescents between 1 and 17 years of age enrolled in a Medicaid Managed Care plan and filled an incident opioid analgesic prescription from 2013 to 2018. A repeat opioid prescription was defined as receiving a subsequent opioid prescription within 30 days from the end of the incident opioid prescription. A generalized linear regression analysis was conducted to examine changes in repeat opioid analgesic dispensing over time at quarterly intervals from January 1, 2013, to December 31, 2018. RESULTS The cohort comprised 17,086 children and adolescents receiving an incident opioid analgesic. Of these, 1780 (10.4%) filled a repeat opioid analgesic prescription. There was a significant decline in the repeat opioid analgesic trend from 11.5% in Q1 2013 to 9.6% in Q4 2018. Stratified analyses by age, sex, and race and ethnicity in a sub-cohort of patients undergoing surgical procedures showed that a significant decline in repeat opioid utilization over time has been observed in all racial/ethnic groups stratified by age and sex, with the most significant decline found in non-Hispanic White children and Hispanic adolescents. At the end of the 6-year follow-up, the racial and ethnic variations in repeat opioid utilization associated with surgical procedures had significantly reduced in children yet persisted among adolescents. CONCLUSIONS Approximately 10% of incident pediatric opioid analgesic recipients received a repeat opioid prescription. There has been a moderate but steady decline (∼7% per quarter) in repeat opioid analgesic utilization between 2013 and 2018.
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Affiliation(s)
- Abhishek A Nair
- Department of Pharmaceutical Health Outcomes and Policy (AA Nair, RR Aparasu, M Johnson, and H Chen), College of Pharmacy, University of Houston, Houston, Tex
| | | | - Harold J Farber
- Department of Pediatrics (HJ Farber), Section of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy (AA Nair, RR Aparasu, M Johnson, and H Chen), College of Pharmacy, University of Houston, Houston, Tex
| | - Michael Johnson
- Department of Pharmaceutical Health Outcomes and Policy (AA Nair, RR Aparasu, M Johnson, and H Chen), College of Pharmacy, University of Houston, Houston, Tex
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy (AA Nair, RR Aparasu, M Johnson, and H Chen), College of Pharmacy, University of Houston, Houston, Tex.
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Zhang SM, Chan YY, Lai LL, Liang PR, Lin M. Parental Postoperative Pain Management Perceptions, Attitudes, and Practices in Pediatric Limb Fractures. Pain Manag Nurs 2023; 24:506-512. [PMID: 37574333 DOI: 10.1016/j.pmn.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 06/11/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Post-surgical pain in children is common, severe, and inadequately controlled. An effective model should involve the participation of parents. AIMS To investigate parental perceptions, attitudes, and practices in postoperative pain management in children with limb fractures and analyze the factors affecting parental practices. DESIGN This was a descriptive cross-sectional study. SETTINGS Research was conducted at a tertiary Children's Hospital Affiliated with Soochow University. PARTICIPANTS Parents whose children (age, 6-18 years) underwent orthopedic fracture surgery between January 1, 2020, and August 31, 2020, were recruited using purposive sampling. METHODS The parents were asked to complete self-report questionnaires: "Pain Management Knowledge and Attitudes Questionnaire" and "Parents' Use of Pain Relief Strategies Questionnaire." The Wong-Baker Faces Scale was used to measure pain intensity in children. The Mann-Whitney U test, Kruskal-Wallis H test, and correlation and regression analyses were used for statistical analyses. RESULTS Data of 180 parents were collected. Of the participants, 80.6%, 78.3%, and 71.7% had low-to-moderate scores for knowledge, general attitudes, and use of pain relief strategies, respectively. Moreover, 93.9% of parents had moderate-to-high scores for negative attitudes toward medication, despite 89.5% of them reporting moderate-to-high pain intensities in their children (median proxy-report of pain intensity, 7.0 [3.00]). Multivariate linear stepwise regression showed that parents' use of pain-relief strategies was related to their general attitudes, knowledge, and sex. CONCLUSIONS Most parents had low-to-moderate scores for perceptions and general attitudes toward children's postoperative pain management, and use of pain relief strategies. Moreover, they lacked knowledge of and had negative attitudes toward pain assessment and analgesics, which significantly impacted their practices. CLINICAL IMPLICATIONS Clinical pediatric nurses should provide appropriate support for the entire family of the child. Moreover, to enhance parental practices, they should develop targeted parental education programs for pain management, particularly regarding pain assessment tools and pain medications.
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Affiliation(s)
- Su-Mei Zhang
- Nursing Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China; Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
| | - Yu-Ying Chan
- Discipline Supervision Office, Children's Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Li-Li Lai
- Nursing Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China; Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Pei-Rong Liang
- Department of Orthopedic Surgery, Children's Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Mao Lin
- Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Cahan EM, Halvorsen KC, Pham NS, Kaur J, Bryson XM, Chan CM, Vorhies JS. Opioid Represcriptions After ACL Reconstruction in Adolescents Are Associated With Subsequent Opioid Use Disorder. J Pediatr Orthop 2023; 43:e273-e277. [PMID: 36652547 DOI: 10.1097/bpo.0000000000002340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Postoperative opioid prescriptions may confer a risk for subsequent opioid use disorders (OUDs). For many children, postoperative analgesia is often the first opioid exposure. The rates of anterior cruciate ligament (ACL) reconstruction in pediatric populations are rising. Here, we use an administrative claims database to describe opioid prescription patterns after ACL reconstruction and their effect on subsequent risk of OUD. METHODS Using International Classification of Diseases (ICD)-9, ICD-10, and CPT codes, we identified patients, with ages 10 to 18, undergoing primary ACL reconstruction between 2014 and 2016 with minimum 1 year follow-up in the Optum Clinformatics Data Mart, which is a nationally representative administrative claims database. Demographic variables and prescription patterns (in morphine milligram equivalents [MMEs]) were analyzed using univariate tests and multivariable logistic regression to determine any potential association with the appearance of anew an ICD-9 or ICD-10 code for OUD within 1 year of the initial procedure. RESULTS A total of 4459 cases were included and 29 (0.7%) of these patients were diagnosed with an OUD within 1 year of surgery. Upon univariate analysis, opioid represcriptions within 6 weeks were significantly more common among patients with OUD; 27.6% vs. 9.7% of patients that did not develop a new diagnosis of OUD ( P =0.005). Multivariable logistic regression indicated an independent significant relationship between total MMEs initially prescribed and the odds of a subsequent OUD diagnosis: for each additional 100 MMEs prescribed in total, the odds of OUD increased by 13% ( P =0.002). Patients with a represcription within 6 weeks of surgery had an average increase in the odds of OUD by 161% ( P =0.027). CONCLUSIONS In this cohort of patient ages 10 to 18 undergoing primary isolated ACL reconstruction, we found substantial variability in opiate prescribing patterns and higher initial opioid prescription volume, as well as opioid represcription within 6 weeks were predictive of the subsequent development of OUD. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Eli M Cahan
- Department of Orthopaedics, Stanford School of Medicine, Palo Alto
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | | | - Nicole S Pham
- Department of Orthopaedics, Stanford School of Medicine, Palo Alto
| | - Japsimran Kaur
- Department of Orthopaedics, Stanford School of Medicine, Palo Alto
| | - Xochitl M Bryson
- Department of Orthopaedics, Stanford School of Medicine, Palo Alto
| | - Charles M Chan
- Department of Orthopaedics, Stanford School of Medicine, Palo Alto
| | - John S Vorhies
- Department of Orthopaedics, Stanford School of Medicine, Palo Alto
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Mittal S, Eftekharzadeh S, Weinstein C, Fombona A, Hyacinthe N, Shah YB, Weiss DA, Kolon TF, Shukla AR, Canning DA, Srinivasan AK, Zaontz MR, Long CJ. Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period? J Pediatr Urol 2023:S1477-5131(23)00023-2. [PMID: 36774243 DOI: 10.1016/j.jpurol.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 01/06/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION & OBJECTIVE The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events. METHODS A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed. RESULTS 1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter. DISCUSSION The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution. CONCLUSIONS The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.
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Affiliation(s)
- Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sahar Eftekharzadeh
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Corey Weinstein
- Department of Urology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Anisleidy Fombona
- Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nathan Hyacinthe
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yash B Shah
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Sidney Kimmel Medical College at Thomas Jefferson University, USA
| | - Dana A Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas F Kolon
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aseem R Shukla
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas A Canning
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Arun K Srinivasan
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark R Zaontz
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher J Long
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Naveen NB, Jaiswal MK, Ganesh V, Singh A, Meena SC, Amburu V, Soni SL. Improved postoperative recovery profile in pediatric oral rehabilitation with low-dose dexmedetomidine as an opioid substitute for general anesthesia: a randomized double-blind clinical trial. J Dent Anesth Pain Med 2022; 22:357-367. [PMID: 36246035 PMCID: PMC9536946 DOI: 10.17245/jdapm.2022.22.5.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 11/05/2022] Open
Abstract
Background Low-dose dexmedetomidine may be a suitable alternative to opioids for pediatric ambulatory procedures under general anesthesia (GA). However, the recovery profile remains unclear. Herein, we aimed to evaluate the effects of low-dose dexmedetomidine on the recovery profile of children. Methods Seventy-two children undergoing ambulatory oral rehabilitation under GA were randomly and equally distributed into two groups (D and F). Group D received an infusion of dexmedetomidine 0.25 µg/kg for 4 min for induction, followed by maintenance of 0.4 µg/kg/h. Group F received an infusion of fentanyl 1 µg/kg over 4 min for induction, followed by maintenance at 1 µg/kg/h. The primary outcome was the extubation time. The secondary outcomes were awakening time, end-tidal sevoflurane (ET-Sevo) requirement, change in hemodynamic parameters, Richmond Agitation-Sedation Scale (RASS), Children's Hospital of Eastern Ontario pain scale (CHEOPS) score, length of PACU stay, and incidence of adverse events. Results Statistically significant differences were observed in the recovery profile between the groups: the median time for extubation was 3.65 (3.44-6.2) vs. 6.25 (4.21-7) minutes in groups D vs. F (P = 0.001), respectively, while the corresponding awakening times were 19 (18.75-21) and 22.5 (22-24) minutes, respectively (P < 0.001). The mean ET-Sevo was low in group D (1.1 vs. 1.2; P < 0.001). The heart rate was significantly low across all time points in group D, without resulting in bradycardia. The median RASS and CHEOPS scores were also significantly lower in group D. No significant differences were observed in the mean arterial pressure, incidence of adverse events, or length of PACU stay. Conclusion Low-dose dexmedetomidine was more effective than fentanyl as an opioid substitute at providing a better recovery profile in pediatric ambulatory oral rehabilitation under GA. Dexmedetomidine also significantly reduced sevoflurane consumption without causing adverse events or prolonging hospital stay.
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Affiliation(s)
- Naik B Naveen
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Kumar Jaiswal
- Department of Pedodontics and Preventive Dentistry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkata Ganesh
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Singh
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shyam Charan Meena
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vamsidhar Amburu
- Department of Critical Care and Emergency Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Shiv Lal Soni
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Mittal S, Eftekharzadeh S, Aghababian A, Shah J, Fischer K, Weaver J, Tan C, Plachter N, Long C, Weiss D, Zaontz M, Kolon T, Zderic S, Canning D, Van Batavia J, Shukla A, Srinivasan A. Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis. J Pediatr Urol 2022; 18:501.e1-501.e7. [PMID: 35803865 DOI: 10.1016/j.jpurol.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/20/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Sahar Eftekharzadeh
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Aznive Aghababian
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Jay Shah
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Katherine Fischer
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - John Weaver
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Connie Tan
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Natalie Plachter
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Christopher Long
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Dana Weiss
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Mark Zaontz
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Thomas Kolon
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Stephen Zderic
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Douglas Canning
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Jason Van Batavia
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Aseem Shukla
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Arun Srinivasan
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA.
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Nair AA, Farber HJ, Chen H. Risk of asthma exacerbation associated with opioid and nonopioid analgesic use in children with current asthma. J Manag Care Spec Pharm 2022; 28:325-335. [PMID: 35199576 PMCID: PMC10373000 DOI: 10.18553/jmcp.2022.28.3.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: In the United States, asthma occurs in a vast proportion of children and adolescents. Asthma exacerbation is an acute episodic event typically characterized by difficulty in breathing, chest tightness, coughing, or wheezing. Severe asthma exacerbation can be life-threatening and lead to service utilizations such as hospitalizations and emergency department (ED) visits. Opioid analgesic use can trigger an asthma exacerbation through 2 pharmacological mechanisms. Despite the potential mechanisms, there is lack of empirical evidence to determine the risk of asthma exacerbation and its association with opioid use. OBJECTIVE: To evaluate the risk of asthma exacerbation in children with current asthma receiving an opioid vs a nonopioid analgesic. METHODS: Eligible individuals aged under 18 years with current asthma and receiving an incident analgesic prescription were identified from a large Medicaid managed care database during 2013-2018. Current asthma was defined as receipt of an asthma diagnosis and an antiasthmatic medication in the 12 months before analgesic medication initiation. Asthma exacerbation was defined as a hospitalization or ED visit with asthma as either the primary or secondary diagnosis within 3 days of receipt of an analgesic prescription. A weighted multivariable logistic regression using inverse probability treatment weighting was performed to test the association between use of analgesic medication and risk of asthma exacerbation. RESULTS: This study included 13,359 children with current asthma who filled either an incident opioid (n = 5,363, 40.1%) or nonopioid analgesic (n = 7,996, 59.9%) prescription. Asthma exacerbation was observed in 24 (0.5%) opioid analgesic recipients and 22 (0.3%) nonopioid analgesic recipients within 3 days of analgesic initiation. Weighted logistic regression results showed that children receiving opioid analgesics (adjusted odds ratio = 1.6, 95% CI = 0.9-2.9) did not have a statistically significantly higher risk of asthma exacerbation than their nonopioid analgesic recipient counterparts in the propensity score-weighted multivariable analysis. CONCLUSIONS: Asthma exacerbation associated with analgesic use in children with current asthma was an uncommon event, and the risk was comparable among children receiving opioid vs nonopioid analgesics. DISCLOSURES: This study was supported and funded by the Agency for Healthcare Research and Quality (AHRQ), Project Number: 1R03HS026790-01A1. The study content was solely the responsibility of the authors, and AHRQ had no role in the design and conduct of the study. The authors have nothing to disclose.
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Affiliation(s)
- Abhishek A Nair
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston TX
| | - Harold J Farber
- Department of Pediatrics, Section of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, and Medical Affairs, Texas Children's Health Plan, Houston, TX
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston TX
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10
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Nair AA, Farber HJ, Chen H. Utilization of opioid versus non-opioid analgesics in Medicaid and CHIP enrolled children with current asthma. Pharmacoepidemiol Drug Saf 2021; 30:1520-1531. [PMID: 34322934 DOI: 10.1002/pds.5336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/17/2021] [Accepted: 07/25/2021] [Indexed: 01/28/2023]
Abstract
PURPOSE Opioid analgesics are frequently dispensed in children despite its known risk in children with a compromised airway function. The objectives of the study were to assess the prevalence of opioid analgesic dispensing in children with current asthma and to identify patient and prescriber factors associated with the dispensing of opioid versus non-opioid analgesics. METHODS Children <18 years of age, having current asthma and receiving an incident analgesic prescription were identified from a large Medicaid Managed Care Plan during years 2013 through 2018. Current asthma was defined as both receiving an asthma diagnosis and filling an anti-asthmatic medication during the 12-month period prior to the analgesic medication initiation. A scoring algorithm was applied to associate analgesic prescription with procedures and diagnoses according to perceived need for analgesia and time proximity. RESULTS Of the 9529 children meeting the inclusion criteria, 2681 (28.1%) received an opioid prescription. Opioid analgesic dispensing was most common among children who had an outpatient surgery/procedure (29.4%), trauma (19.4%) dental procedure (18.4%), and respiratory infection (10.6%). Multivariable analysis indicated that non-Hispanic Black (AOR: 0.39[0.3-0.5]) and Hispanic (AOR: 0.51[0.4-0.6]) children were less likely to receive an opioid analgesic compared to their non-Hispanic White counterparts. Children with prior history of asthma-related emergency department visit (AOR: 1.24[1.0-1.5]) and short acting beta agonist overuse (AOR: 1.33[1.1-1.7]) were more likely to fill an opioid analgesic prescription than those without. CONCLUSION Opioid analgesics are frequently dispensed to children with asthma. A higher dispensing rate was observed among non-Hispanic White children and among those with a history of uncontrolled asthma.
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Affiliation(s)
- Abhishek A Nair
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Harold J Farber
- Department of Pediatrics, Section of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Medical Affairs, Texas Children's Health Plan, Houston, Texas, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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11
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Parental Psychosocial Factors Moderate Opioid Administration Following Children's Surgery. Anesth Analg 2021; 132:1710-1719. [PMID: 33177324 DOI: 10.1213/ane.0000000000005255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND This investigation aimed to examine the impact of parental psychosocial variables on the administration of opioids to young children experiencing postoperative pain. METHODS Participants in this longitudinal analysis were children ages 2-12 undergoing tonsillectomy with or without adenoidectomy and their parents. Parents completed validated instruments assessing trait anxiety, perceived stress, and coping style before surgery, and children and parents completed instruments assessing pain and administration of opioids and acetaminophen on days 1, 2, 3, and 7 at home after surgery. The structure of the data was such that parents and children completed multiple data assessments making the data multilevel (ie, days of data within dyads). To address this issue of data structure, multilevel modeling was used to analyze the dataset. RESULTS Participants included 173 parent-child dyads (mean child age = 5.99 ± 2.51) recruited between 2012 and 2017. We found that parent-related psychosocial variables, such as trait anxiety, stress, and coping style, moderated the relationship between the child's pain and postoperative medication administration. Specifically, when predicting hydrocodone, the interactions between anxiety and pain and stress and pain were significant; when child pain was high, high-anxiety and high-stressed parents gave their children 19% and 12% more hydrocodone, respectively, compared to low-anxiety and low-stressed parents. When predicting acetaminophen, the interactions between anxiety and pain, a blunting coping style and pain, and a monitoring coping style and pain were significant. CONCLUSIONS These results suggest the need to identify parents who experience high levels of perceived stress and trait anxiety and use appropriate interventions to manage stress and anxiety. This may ensure children receive optimal amounts of pain medication following surgery.
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Phan MT, Wong C, Tomaszewski DM, Kain ZN, Jenkins B, Donaldson C, Fortier M, Yang S. Evaluating Opioid Dispensing Rates among Pediatrics and Young Adults based on CURES Data Reporting in California from 2015-2019. JOURNAL OF CONTEMPORARY PHARMACY PRACTICE 2021; 67:23-32. [PMID: 34368640 DOI: 10.37901/jcphp20-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Receipt of opioid prescriptions in pediatric and young adult patients may be a risk factor for future opioid misuse. Data from prescription drug monitoring programs provide insight on outpatient opioid use. In our study, we analyzed the opioid dispensing rates for pediatrics and young adults in California. Methods A secondary analysis was performed from 2015-2019 using Controlled Utilization Review and Evaluation System data. This database provides dispensing data of controlled substances in California. Patients younger than 25 years who were prescribed opiates were analyzed by county. We further divided them into two groups (children: ≤14 years; adolescents and young adult: 15-24 years). Descriptive statistics and heat maps were used to illustrate the trends in opioid usage among different age groups. Results The overall percentages for the number of opioids being dispensed to patients aged <25 years have decreased over the past four years. In 2015, 6 out of 58 counties in California were considered "high-rate" with >2.9% of opioids dispensed to patients younger than 25 years old; in 2019, this number reduced to zero. Patients 25 and older received a higher proportion of opioids compared to younger populations; in 2019, 35.91% of opioids were dispensed to patients 45-64, and 8.92% to patients younger than 25. Conclusion Pediatric opioid prescriptions have declined over the recent years. However, a high degree of variability of prescription rates between demographic counties was noted. More studies are warranted in order to understand this discrepancy in opioid prescribing among pediatric and young adult patients.
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Affiliation(s)
| | | | - Daniel M Tomaszewski
- Department of Pharmaceutical and Health Economics at the University of Southern California's School of Pharmacy
| | - Zeev N Kain
- Department of Anesthesiology & Perioperative Care at the University of California, Irvine School of Medicine
| | - Brooke Jenkins
- Crean College of Health and Behavioral Sciences at Chapman University
| | - Candice Donaldson
- Crean College of Health and Behavioral Sciences at Chapman University
| | - Michelle Fortier
- Sue & Bill Gross School of Nursing, UCI Center on Stress & Health, Department of Anesthesiology & Perioperative Care, and Department of Pediatric Psychology, CHOC Children's
| | - Sun Yang
- Chapman University School of Pharmacy
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13
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Mann GE, Flamer SZ, Nair S, Maher JN, Cowan B, Streiff A, Adams D, Shaparin N. Opioid-free anesthesia for adenotonsillectomy in children. Int J Pediatr Otorhinolaryngol 2021; 140:110501. [PMID: 33290925 DOI: 10.1016/j.ijporl.2020.110501] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Opioids are administered during the intraoperative and postoperative periods in pediatric adenotonsillectomy and tonsillectomy. Non-opioid analgesics are often used as an analgesic during pediatric adenotonsillectomy and tonsillectomy. In this hypothesis generating study, we are evaluating safety and efficacy of stand-alone opioid analgesia for adenotonsillectomy and tonsillectomy. METHODS This is a single-center retrospective chart review of patients ages 2 to 13 who underwent elective adenotonsillectomy and tonsillectomy. We used a convenience sampling method to select patients who received intraoperative intravenous fentanyl, acetaminophen, ibuprofen, or any combination thereof. The following outcomes were analyzed in this study: (i) the length of Post Anesthesia Care Unit stay, (ii) administration of postoperative opioids; (iii) postoperative opioid equivalents required; (iv) administration of postoperative non-opioid analgesics; and (v) inpatient admission from ED within 30 days. We used univariate analysis to compare the data points. RESULTS We analyzed data from 323 patients who underwent adenotonsillectomy and tonsillectomy. The Post Anesthesia Care Unit length stay was similar for the intraoperative opioid-free and intraoperative opioid groups, 146.68 (±67.35) and 143.18 (±37.85) minutes, respectively (p = 0.586). Additionally, 102 patients (73.4%) in the intraoperative opioid-free group and 184 patients (83.2%) in the intraoperative opioid group did not receive any postoperative opioids (p = 0.033). The incidence of adverse events was similar between the intraoperative opioid-free and intraoperative opioid groups 3 (2.2%) and 5 (2.7%) respectively, p-value 0.749. A subgroup analysis comparing extracapsular 235 (72.8%) versus intracapsular 88 (27.2%) tonsillectomy yielded similar results. CONCLUSION In this study, our data indicates that American Society of Anesthesiologists I- II pediatric patients undergoing adenotonsillectomy and tonsillectomy can be efficiently and safely managed with an opioid-free intraoperative and postoperative analgesic regimen. Due to the explained limitations, our study results should be interpreted cautiously.
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Affiliation(s)
- Glenn E Mann
- Albert Einstein College of Medicine, Bronx, USA; Montefiore Medical Center, Department of Anesthesiology, USA.
| | | | - Singh Nair
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - James N Maher
- Icahn School of Medicine at Mount Sinai, Department of Anesthesiology, Perioperative and Pain Medicine, USA
| | - Brandon Cowan
- Oakland University William Beaumont School of Medicine, USA
| | - Agathe Streiff
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - David Adams
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - Naum Shaparin
- Albert Einstein College of Medicine, Bronx, USA; Montefiore Medical Center, Department of Anesthesiology, USA
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Benchetrit L, Kwock M, Ronner EA, Goldstein S, Shu E, Lee DJ, Mankarious LA, Caloway C, Kempfle J, Cohen MS. Assessment of Pain and Analgesic Use in Children Following Otologic Surgery. Otolaryngol Head Neck Surg 2020; 165:206-214. [PMID: 33287651 DOI: 10.1177/0194599820971183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To compare postoperative pain and analgesic use in children following transcanal endoscopic ear surgery (TEES) vs non-transcanal endoscopic ear surgery (non-TEES). STUDY DESIGN Prospective case series. SETTING Tertiary care center. METHODS Surveys using the Wong-Baker FACES Pain Rating Scale and recording the frequency and dosage of consumed analgesics were administered prospectively to caregivers of children undergoing otologic surgery between May 2018 to February 2020. Pain intensity and medication use were recorded twice daily for 6 days, starting on postoperative day 0. Mean pain scores and mean number of consumed analgesic doses were compared between groups. RESULTS Survey response rate was 57.9%. Among 53 patients who completed the survey, 35 (66.0%) underwent TEES and 18 (34.0%) underwent non-TEES. Mean pain ratings on postoperative days 0 and 1 were significantly lower among children undergoing TEES (2.2 and 2.1) vs non-TEES (4.0 and 4.1), P = .045 and P = .008, respectively (Mann-Whitney U test). The mean pain ratings across the 6 days were similar in TEES (1.7) and non-TEES (2.6) (P = .140, Mann-Whitney U test). The mean number of analgesic doses consumed per half-day over the 6 days was significantly lower among children undergoing TEES (0.3) vs non-TEES (0.6; P = .049, Mann-Whitney U test). CONCLUSION Postoperative pain following TEES and non-TEES in children was overall low. Children undergoing TEES had a small but statistically significant decrease in pain on postoperative days 0 and 1 and decreased use of pain medications compared to non-TEES.
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Affiliation(s)
- Liliya Benchetrit
- Department of Otolaryngology-Head and Neck Surgery, Boston University Medical Center, Boston, Massachusetts, USA
| | - Megan Kwock
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Evette A Ronner
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Sheli Goldstein
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Edina Shu
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Daniel J Lee
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Leila A Mankarious
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Christen Caloway
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Judith Kempfle
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Michael S Cohen
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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15
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Mittal S, Shukla AR, Sahadev R, Lee SY, Siu S, Gale EM, Plachter N, Srinivasan AK. Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative. J Pediatr Urol 2020; 16:846.e1-846.e7. [PMID: 33132029 DOI: 10.1016/j.jpurol.2020.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/10/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms. OBJECTIVE To measure the efficacy of a quality improvement initiative aimed to reduce post-operative opioids for pain management in a large pediatric surgical cohort. STUDY DESIGN Patients undergoing ambulatory pediatric urologic surgery at a tertiary children's hospital between July 2016 to June 2019 were analyzed. Structured physician peer-to-peer comparisons, electronic health record redesign and a standardized pain management protocol were implemented. Rate of opioid prescriptions per month, utilization of non-opioid analgesia, unplanned encounters in the emergency department and/or office during implementation were aggregated. Opioid doses and prescribed opioid days before and after protocol implementation were analyzed. A subcohort, from October-December 2018 was administered a patient-reported outcome questionnaire focused on pain management and return to baseline activity. RESULTS A total of 6684 consecutive outpatient urologic cases were included (median age = 3.3 years old (IQR 0.9-9.2) and 92.3% male). Comparing 6 months pre-intervention and the post-intervention latest 6 month intervals, opioid prescription rate decreased from 43.9% to 2.3% (p < 0.001). Additionally, non-opioid analgesia with ketorolac increased from 30.7% to 50.6% (p < 0.001). Concurrently, no differences in the rate of office visits within 5 days, overall ED visits, ED visits for pain or for bleeding within 30 days after implementation were identified. Between October to December 2018, 373 cases were performed and a Patient-Reported Outcome (PRO) questionnaire was completed for 128 of those patients (34%). Families reported a low patient pain score of 3.7 (SD 2.4) and a rapid postoperative recovery time of a median 2 (IQR 1-4) days to full resumption of pre-operative level of activity. High satisfaction with opioid reduction in post-operative pain management was reported (median score of 10 (IQR 8-10)). CONCLUSION Opioid prescriptions and utilization may be minimized without increasing unplanned encounters or adversely affecting quality of life. The QI framework utilized in this process can be implemented to reduce opioid exposure in other surgical patient populations.
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Affiliation(s)
- Sameer Mittal
- Children's Hospital of Philadelphia, Philadelphia PA, USA.
| | - Aseem R Shukla
- Children's Hospital of Philadelphia, Philadelphia PA, USA
| | | | - Seo Y Lee
- Children's Hospital of Philadelphia, Philadelphia PA, USA
| | - Sharmayne Siu
- Children's Hospital of Philadelphia, Philadelphia PA, USA
| | - Erica M Gale
- Children's Hospital of Philadelphia, Philadelphia PA, USA
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Squillaro AI, Ourshalimian S, McLaughlin CM, Lakshmanan A, Friedlich P, Gong C, Song A, Kelley-Quon LI. Postoperative Opioid Analgesia Impacts Resource Utilization in Infants Undergoing Pyloromyotomy. J Surg Res 2020; 255:594-601. [PMID: 32652313 PMCID: PMC7541571 DOI: 10.1016/j.jss.2020.05.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/14/2020] [Accepted: 05/24/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opioid analgesia is often avoided in infants undergoing pyloromyotomy. Previous studies highlight an association between opioid use and prolonged hospitalization after pyloromyotomy. However, the impact of opioid use on healthcare resource utilization and cost is unknown. We hypothesized that use of opioids after pyloromyotomy is associated with increased resource utilization and costs. METHODS A retrospective cohort study was conducted identifying healthy infants aged <6 mo with a diagnosis of pyloric stenosis who underwent pyloromyotomy from 2005 to 2015 among 47 children's hospitals using the Pediatric Health Information System database. Time of opioid exposure was categorized as day of surgery (DOS) alone, postoperative use alone, or combined DOS and postoperative use. Primary outcomes were the standardized unit cost, a proxy for resource utilization, billed charges to the patient/insurer, and hospital costs. A multivariable log-linear mixed-effects model was used to adjust for patient and hospital level factors. RESULTS Overall, 11,008 infants underwent pyloromyotomy with 2842 (26%) receiving perioperative opioids. Most opioid use was confined to the DOS alone (n = 2,158, 19.6%). Infants who received opioids on DOS and postoperatively exhibited 13% (95% confidence interval [CI]: 7%-20%, P-value <0.001) higher total resource utilization compared with infants who did not receive any opioids. Billed charges were 3% higher (95% CI: 0%-5%, P-value = 0.034) for infants receiving opioids isolated to the postoperative period alone and 6% higher (95% CI: 2%-11%, P-value = 0.004) for infants receiving opioids on the DOS and postoperatively. CONCLUSIONS Postoperative opioid use among infants who underwent pyloromyotomy was associated with increased resource utilization and costs.
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Affiliation(s)
- Anthony I Squillaro
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Cory M McLaughlin
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Ashwini Lakshmanan
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
| | - Philippe Friedlich
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Cynthia Gong
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA
| | - Ashley Song
- Department of Preventive Medicine at Johns Hopkins School of Medicine
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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