Factors Associated With the Prophylactic Prescription of a Bowel Regimen to Prevent Opioid-Induced Constipation

Quantifying the intensity of adverse events with ibuprofen and oxycodone: an observational cohort study

OBJECTIVE

To quantify the frequency and intensity of adverse events (AEs), commonly known as side effects, experienced by children receiving either ibuprofen or oxycodone for pain management following an acute fracture. Secondary objectives were to quantify functional outcome impairment and describe demographic and clinical characteristics associated with AEs.

DESIGN

Observational cohort study.

SETTING

Paediatric emergency department.

PATIENTS

Patients (n=240) aged 4-16 years diagnosed with an acute fracture.

INTERVENTION

Prescribed either ibuprofen (n=179) or oxycodone (n=61) for pain.

MAIN OUTCOME MEASURES

Families were called for the first 3 days after discharge to report the presence and intensity of AEs and their child's functional outcomes (ability to eat, sleep, play or attend school).

RESULTS

On day 1, children using oxycodone were more likely to report any AE (χ² ₁=13.5, p<0.001), nausea (χ² ₁=17.0, p<0.001), vomiting (χ² ₁=11.2, p<0.001), drowsiness (χ² ₁=13.7,p<0.001), constipation (χ² ₁=8.9, p=0.003) and dizziness (χ² ₁=19.1, p<0.001), compared with those using ibuprofen. Children receiving oxycodone reported greater severity of abdominal pain (oxycodone: mean 5.4 SD 3.1; ibuprofen mean 2.5 SD 1.4, F¹ ₁₃=6.5, p=0.02) on day 1 and worse intensity of constipation (oxycodone: mean 4.9 SD 2.1; ibuprofen mean 3.2 SD 2.2, F¹ ₃₃=4.5, p=0.04) over all 3 days. Use of oxycodone was associated with an increased odds of experiencing an AE on day 1 (OR=1.31 (95% CI 1.13 to 1.52)). Higher pain scores (OR=1.50 (95% CI 1.12 to 2.01)), lower extremity fracture (OR=1.25 (95% CI 1.07 to 1.47)) and undergoing ED sedation (OR=1.16 (95% CI 1.01 to 1.34)) were associated with missing school. Higher pain scores (OR=1.50 (95% CI 1.14 to 1.97)) and lower extremity fractures (OR=1.23 (95% CI 1.07 to 1.43)) were also associated with less play.

CONCLUSIONS

Oxycodone is associated with more frequent AEs overall, higher intensity gastrointestinal AEs and greater functional limitations compared with ibuprofen. Lower extremity fractures cause more functional limitations than upper extremity fractures. Clinicians should consider these differences when providing fracture pain care for children.

Reducing Opioid-Induced Constipation Post-Cardiac Surgery: An Improvement Project in a Pediatric Cardiac Intensive Care Unit

BACKGROUND

Pain management with opioids and underutilization of prophylaxis for constipation can prolong a patient's hospital length of stay and impede pain management efforts.

PROBLEM

In pediatric postoperative cardiac patients, opioid therapy is a common approach to pain management but often places them at greater risk for constipation due to anatomy and age.

METHODS

A retrospective review of 50 patients' medical records for baseline data was conducted, and a survey evaluated providers' current knowledge and practice.

INTERVENTIONS

The intervention was an electronic order set that provided decision support. Additionally, prophylactic measures were supported by a validated assessment tool that created a common language to report constipation risk.

RESULTS

Although not statistically significant, postintervention data demonstrated a 21.5% decrease in postoperative constipation and a 57% increase in ordered bowel regimens.

CONCLUSION

More focus is needed toward prophylactic bowel regimens to reduce the risk in this already high-risk population.

Creating a bowel management plan for pediatric orthopaedic spine surgery patients

PURPOSE

Opioid-induced constipation is a common problem in patients who have undergone surgery. No standard gastrointestinal protocol exists to manage perioperative care in pediatric orthopaedic spinal fusion patients despite data which support the need for a bowel regimen while a patient is taking narcotics. At our institution, this group of patients often present to the emergency department with constipation and other gastrointestinal complaints. We developed a quality improvement initiative to create a standardized bowel management plan for pediatric patients undergoing orthopaedic spine surgery to decrease constipation, thus improving care, and minimizing unplanned visits.

METHODS

We developed a bowel management plan in collaboration with the gastroenterology team, created an Epic Smart Phrase for discharge instructions to enhance compliance, and created and dispersed informational communication on changes to constipation management. We monitored compliance, emergency department visits, and re-admissions.

RESULTS

Compliance with the bowel management plan, including inpatient medication prescribing and discharge "at-home" education, has increased to a mean of 93%. Emergency Department (ED) visits or re-admissions for constipation were reduced from a baseline mean of 1 in every 11 cases, to 1 in every 184 cases. Our institution sustained more than 2 years without an ED visit or readmission related to constipation in this patient population after the bowel management plan was in place.

CONCLUSION

A bowel management plan can be used in the care of pediatric spinal fusion patients to increase patient safety, decrease healthcare burden, and improve care. This project not only increased awareness of post-surgical gastrointestinal symptoms and opioid side effects, but also decreased post-operative emergency department visits and re-admissions related to constipation.

LEVEL OF EVIDENCE

III, case control study.

Rates of appropriate laxative prophylaxis for opioid-induced constipation in veterans with lung cancer: a retrospective cohort study

PURPOSE

Opioid-induced constipation (OIC) is the most common side effect in patient-prescribed opioids for cancer pain treatment. Current guidelines recommend routine prescription of a laxative for preventing OIC in all patients prescribed an opioid unless a contraindication exists. We determined patterns of prescription of laxative agents in patients with lung cancer initiating opioids.

METHODS

We performed a retrospective cohort study evaluating the prescription of laxatives for OIC to adult patients with incident lung cancer seen in the Veteran's Affairs (VA) system, between January 1, 2003, and December 31, 2016. Exposure to laxative agents was categorized as follows: none, docusate monotherapy, docusate plus another laxative, and other laxatives only. Prevalence of OIC prophylaxis was analyzed using descriptive statistics. Linear regression was performed to identify time trends in the prescription of OIC prophylaxis.

RESULTS

Overall, 130,990 individuals were included in the analysis. Of these, 87% of patients received inadequate prophylaxis (75% no prophylaxis and 12% docusate alone), while 5% received OIC prophylaxis with the unnecessary addition of docusate to another laxative. Through the study period, laxative prescription significantly decreased, while all other categories of OIC prophylaxis were unchanged. We noted an inverse relationship with OIC prophylaxis and likelihood of a diagnosis of constipation at 3 and 6 months.

CONCLUSIONS

In this study of veterans with lung cancer, almost 90% received inadequate or inappropriate OIC prophylaxis. Efforts to educate physicians and patients to promote appropriate OIC prophylaxis in combination with systems-level changes are warranted.